HIV
	 — 
	Question

Lord Fowler: To ask Her Majesty’s Government what estimate they have made of the proportion of people living with HIV who are undiagnosed.

Earl Howe: My Lords, Public Health England estimates that in 2013 107,800 people were living with HIV in the United Kingdom. Of these, 24%, some 26,100, down from 25% in 2012, were undiagnosed and unaware of their infection. Early diagnosis is important to ensure people can get early treatment and to prevent them infecting others.

Lord Fowler: My Lords, surely we cannot ever eradicate HIV in Britain, which currently is costing the health service something like £650 million a year, when there are at any one time, as my noble friend has just said, 26,000 people who have contracted HIV but are undiagnosed and untested and can obviously spread the infection further. Will my noble friend consider setting up a working party to report on how testing in this country can be improved, which would be of benefit to those people affected and also to the benefit of the public generally.

Earl Howe: I will gladly take that suggestion from my noble friend away and give it consideration and I am grateful to him for it. The position on testing is, however, quite encouraging. We have seen more than 1 million HIV tests in sexual health clinics in 2013, which is up 5% from the previous year, and that is only in sexual health clinics. As my noble friend knows, there are other routes to testing through GP surgeries, self-sampling kits and so on. Additional testing is vital if we are going to make sufficient inroads into diagnosing this condition.

Baroness Barker: My Lords, the organisation Halve It reported in a survey last year that one-third of GPs who are in high-prevalence HIV areas were unaware that that is where they worked and consequently were not testing people for HIV routinely. Can the Government work with Public Health England and the RCGP to remedy that?

Earl Howe: My Lords, I pay tribute to the work of the Halve It coalition in raising awareness about the importance of increasing HIV testing. My noble friend is right that apart from ignorance often GPs are reluctant to discuss HIV testing or are unaware of the importance of early diagnosis and possible indicator
	symptoms. My department was pleased to fund the Medical Foundation for AIDS and Sexual Health’s HIV testing in primary care project that provides a web-based interactive resource for GPs in primary care to help make testing easier in GP surgeries.

Baroness McIntosh of Hudnall: My Lords, does the Minister agree that one of the biggest disincentives to testing is the amount of stigma that still remains against those who are known to have HIV? Alongside encouraging people to have tests, can he say what Public Health England is doing to combat that stigma?

Earl Howe: The noble Baroness is absolutely right. If we were to single out three things that are important in this context, they would be prevention, testing and tackling stigma and discrimination. The NHS, local authorities, government, community and faith groups, the media and individuals themselves all have a part to play in eliminating HIV-related stigma. Our framework for sexual health improvement is clear that action needs to continue to eradicate prejudice based on sexual orientation. That depends on building an open and honest culture where everyone can make informed decisions and responsible choices about relationships.

Baroness Gardner of Parkes: My Lords, is it not a fact that there has been a great change in attitudes about HIV, and not only because of the treatments that are now available? I recall the days when people went into a hospice because it was a terminal condition. I have sat on various inquiries and know that people used to hide—in the fridge, for example —any evidence that they had HIV because they were frightened of other people knowing. Because that no longer applies, there is a great opportunity for people to have testing without any embarrassment at all.

Earl Howe: My noble friend is right. I think that we have come a long way since my noble friend Lord Fowler was Secretary of State, when stigma and discrimination were very apparent in virtually all sections of society. We do not see that so much now, I am glad to say, as evidenced by the fact that we are reporting a continuing reduction in late diagnosis. It was down to 42% last year from 47% in 2012, and that is a key indicator in this context.

Lord Collins of Highbury: My Lords, the UK is a leading supporter of research and development into universal prevention methods, including HIV microbiocides and vaccines. With 19 million people globally remaining unaware of their HIV status today, will the noble Earl tell us how the Department of Health is working with the Department for International Development to support this research and development work?

Earl Howe: My Lords, in November 2013 DfID conducted a review of our 2011 HIV position paper. The review paper highlighted three areas of particular focus in the international context. They were to identify the key affected populations—girls and women—and the integration of HIV responses into the wider health
	system, as well as broader development priorities. That of course includes tackling stigma and the unacceptable things that we see in certain overseas countries, including discriminatory legislation.

Lord Patel: My Lords, did the Minister refer to 26,000 people being undiagnosed? What is that number based on?

Earl Howe: My Lords, these figures inevitably have to be estimates but they rely on data from three surveys that measure undiagnosed HIV infection among sexual health clinic attendees, pregnant women and people who inject drugs. Comprehensive clinical data from sexual health clinics relating to patients newly diagnosed with HIV are also used to infer the risk of undiagnosed infection.

Lord McConnell of Glenscorrodale: My Lords, moving the focus from sub-Saharan Africa, where we have been so focused over recent years, is the Minister aware of the increase in the incidence of HIV/AIDS in south-east Asia? Are the Government looking at advice to British tourists travelling to that area in the light of this increase in the incidence?

Earl Howe: My Lords, I believe I am right in saying that there is advice on the FCO website for tourists to that part of the world. However, if I may, I will write to the noble Lord with details of the factors that obtain in south-east Asia.

Personal Independence Payments
	 — 
	Question

Lord Dubs: To ask Her Majesty’s Government what steps they are taking to ensure that people facing delays in receiving personal independence payments do not endure financial hardship.

Lord Bourne of Aberystwyth: My Lords, personal independence payment is not an income replacement benefit; it contributes towards the extra costs associated with disability. Employment support allowance provides financial support for those who are ill or disabled and unable to work. We appreciate the difficulties associated with claims for PIP, and we are absolutely committed to reducing the backlog, and waiting times. Monthly clearances have quadrupled over the past year, and the backlog is falling. All successful new PIP claims are backdated.

Lord Dubs: I thank the Minister for that reply, but will he nevertheless confirm that, as recently as last month, some 670,000 people had registered for PIP but 300,000 people were still waiting for their claim to be processed, some of whom had been waiting for six months or longer? The system is not fit for
	purpose, yet the Government are still rolling out the scheme. Is it not right for them to stop the rollout until the system is working, to assess the negative impact on hundreds and thousands of handicapped disabled people, and to make sure that it is fit for purpose before they proceed?

Lord Bourne of Aberystwyth: My Lords, I dispute those figures. The backlog stands at 107,000 at the moment, and 65,000 claims are being processed every month. Help is available in other areas—such as JSA, ESA, local authority help and NHS help—for those who are awaiting an assessment. The system is not failing; it is succeeding, and the backlog is being cleared.

Baroness Eaton: May I ask the Minister what assessment Her Majesty’s Government have made of the recent report from the all-party parliamentary inquiry into hunger and food poverty?

Lord Bourne of Aberystwyth: My Lords, the Government have looked closely at the all-party parliamentary group’s report on food banks and food poverty. It is a complex issue; there is no doubt about that. We have, of course, identified ways in which we can further publicise hardship payments, and we are doing that. We are also looking, with food retailers, at how we can ensure that food waste is minimised. The private sector has a role to play there.

Lord Touhig: My Lords, many claimants with autism lack insight into their own condition, and a family member or companion can help fill in the gaps during the PIP interview. But the National Autistic Society, of which I am a vice-president, tells me that a number of assessors are refusing to allow that. Will the Minister look into this? It is discrimination. Will he ensure that people who are autistic are not adversely affected by this attitude?

Lord Bourne of Aberystwyth: The noble Lord does notable work in the area of autism, as is well known. The guidelines on the medical assessments related to PIP indicate that all these conditions should be taken account of. I have no evidence of this being a particular problem, but if the noble Lord would like to write to me about it, I will ensure that it is looked at.

Baroness Sherlock: My Lords, last June, Iain Duncan Smith told MPs that by the end of 2014 nobody would be waiting more than 16 weeks for a PIP assessment. Can the Minister tell the House precisely when that target will be met? I do not believe that it was met by the end of 2014. As the target was only for when people would get an assessment, can he also tell the House how long people will have to wait to get a final decision, and their money? He seemed to be reassuring the House that people would get their money backdated when they eventually got it, but is it not the case that, even though PIP is backdated, passported benefits such as blue badges and carer’s allowance are not?

Lord Bourne of Aberystwyth: The noble Baroness has asked a range of questions, and if I fail to answer all of them now, no doubt we can speak later. We are clearing the backlog and, as she will know, there has been significant progress. I shall repeat the figures: the backlog is coming down and we are clearing 65,000 claims a month. The Minister in another place, Mark Harper, will report on progress to the Work and Pensions Select Committee on 28 January. The rate of clearances is improving month on month, and the number of outstanding cases in the system has been falling significantly.

Lord Hylton: Last year, food banks served 500,000 people in six months. If people cannot even afford food, does that not show that there is acute financial hardship? Will the Government therefore try to reduce the number of people suffering sanctions and make sure that sanctions last for the minimum possible period?

Lord Bourne of Aberystwyth: The noble Lord draws attention to the important role that food banks are fulfilling. Food banks have existed for well over a decade throughout western Europe, the USA and Canada. The reasons for using food banks are many and complex, and I pay tribute to what they are doing. As I say, to address some of the concerns we are publicising much more the possibility of early payment of hardship benefit and so on, and we are working with food retailers on food waste.

Lord German: My Lords—

Lord McFall of Alcluith: My Lords—

Baroness Stowell of Beeston: My Lords, we have heard from several Peers from the Labour Benches on this Question and we have not yet heard from a Liberal Democrat Member.

Lord German: My Lords, the loss of a Motability car can mean the loss of independence for a disabled person. Is my noble friend confident that the personal independence payment assessors are prompting claimants as to whether they can walk more than 20 metres safely to an acceptable standard repeatedly and in a reasonable time, which are the crucial criteria put into statute by this House? Unless these criteria are followed, thousands of disabled people will not be eligible for a Motability car and those being retested may lose their car and their independence.

Lord Bourne of Aberystwyth: My noble friend raises important issues on the subject of Motability cars. It is worth noting that the Motability payment will continue while it is being reassessed. Those four criteria are looked at very closely. The legislation requires the assessors to consider whether a claimant can carry out each activity reliably. They will do that by means of observation, discussion and medical evidence—often just on the basis of medical evidence. I am satisfied that those criteria are being followed.

United States: Haggis Ban
	 — 
	Question

Lord McColl of Dulwich: To ask Her Majesty’s Government what steps they are taking to persuade the United States to lift its ban on the import of haggis.

Lord De Mauley: My Lords, the United States Food and Drug Administration does not allow animal lungs in products for human consumption. My right honourable friend the former Secretary of State Owen Paterson lobbied the US authorities during his visit in the summer, and we continue to encourage them to adjust their ban on haggis containing sheep lungs as part of the wider European Union negotiations on lifting the transmissible spongiform encephalopathy restrictions on EU lamb.

Lord McColl of Dulwich: I thank the noble Lord for his usual courteous and informative reply. Is he aware that the United States Government are depriving 24 million American Scots of this wholesome food, which satisfies hunger very much more than the junk food the Americans consume? It would help to deal with the greatest epidemic they have—the obesity epidemic, which is killing millions, costing billions of dollars, and for which the cure is free. Will the Minister encourage the Government to redouble their efforts to persuade the American Government to have much freer trade and lift the 1971 ban on the wholesome haggis?

Lord De Mauley: Well, my Lords, there is quite a lot in that. Perhaps it would help if I explained that two hurdles are involved in what the noble Lord proposes. We have to get over, first, the US restrictions on the import of lamb. We are working with the US authorities towards achieving approval to lift those restrictions with, I think, good prospects. Secondly, there is the US’s unwillingness to recognise animal lungs as an acceptable foodstuff. In this regard the most promising avenue in the short term is the production of haggis omitting the inclusion of lung—and the Scottish Government recognise this.

Lord Purvis of Tweed: My Lords, I appreciate that not everyone fully understands the haggis. Once for a Burns supper in Germany, Burns’s,
	“Great chieftain o’ the puddin-race!”,
	was translated into German and then retranslated back as, “Mighty Führer of the sausage people”. Will the Minister make sure that this ridiculous ban comes to an end? If it is not too late, I see that the Prime Minister is with President Obama today, so can my noble friend send an urgent message to make sure that this visit is a triumph by having a private word with the President to make sure that the ban is now lifted?

Lord De Mauley: Unfortunately, I cannot guarantee a rapid resolution of the problem, but I hope I have made clear that we are working extremely hard towards it. Promoting food and drink exports more generally is a key government priority. We are working hard to
	champion UK food and drink overseas with, I think, considerable success. My right honourable friend the Secretary of State is currently in China doing just that.

Lord Winston: My Lords, I confess to being a little surprised that one of the most senior qualified medical practitioners in the Chamber is asking this Question, seeing that there is a questionable issue about haggis—which I, personally, find a revolting food. Would not charity be better at home? If haggis does indeed deal with obesity, perhaps we should promote it a little in Glasgow.

Lord De Mauley: My Lords, what a good idea. As the noble Lord does not appear to like the taste of the,
	“Great chieftain o’ the pudding-race”,
	I recommend a large tot of whisky.

Lord Forsyth of Drumlean: My Lords, given the seriousness of this matter, should the Government not consider appointing a special envoy with energy and imagination to go to the United States and stay there until this matter is resolved? Could I suggest that Alex Salmond is currently looking for work?

Lord De Mauley: My Lords, I was going to say that it is a question of priorities, but that is an eminently sensible suggestion.

Lord Cormack: My Lords, what is served at the British embassy on Burns Night?

Lord De Mauley: What else, my Lords? Haggis.

Milk Production
	 — 
	Question

The Lord Bishop of St Albans: To ask Her Majesty’s Government what steps they are taking to ensure the long-term sustainability of milk production in the United Kingdom.

Lord De Mauley: My Lords, we share farmers’ concerns over the pressures on milk prices caused by the volatility of the global market and we are working closely with industry. It is important to remember that the long-term prospects are good, with exports at record levels. We are helping the dairy industry take advantage of opportunities such as opening new export markets and pushing for better country of origin labelling for British dairy products.

The Lord Bishop of St Albans: I thank the Minister for his Answer. Does he agree that, should we lose any of our capacity to produce milk due to the very low prices of imported milk at the moment, the nature of the dairy industry is such that you cannot quickly and efficiently turn it back on again when another shortage occurs—as there clearly will be at some point? What are Her Majesty’s Government doing to draw together dairy farmers, processors and, above all, retailers so
	that we can guarantee the long-term viability of our dairy industry and also ensure that the prices of milk reflect the costs of production?

Lord De Mauley: My Lords, to address the short-term problem, my honourable friend George Eustice, the farms Minister, yesterday held a farming resilience summit precisely so that this subject could be a central focus. Noble Lords may also have seen that DairyCo has offered advice and assistance to farmers in cash-flow planning and volatility management. Other actions in hand include investigating whether the seasonal cyclicality of prices lends itself to the use of futures markets to smooth the price curve, and we are putting pressure on the Commissioner to accelerate the improvement of country-of-origin labelling.

Lord Wigley: Does the Minister accept that there is a need for long-term stability for the dairy sector to flourish, and that a price below 29 pence a litre at farm gate, which was the average price in November, is not sustainable? Does he accept that action needs to be taken? Does he believe that the steps to which he referred with regard to co-operation with our European partners in dairy matters on the question of labelling is enough to deliver what is needed for that stability?

Lord De Mauley: I certainly agree with the first half of what the noble Lord has said. I am not suggesting that the work on labelling is by any means the only tool. That is why, as I have said, we are looking at the use of futures markets, because there is evidence of a seasonal cyclicality of milk prices. At certain times of the year a crunch tends to be worse, and such crunches can be foreseen, so we want to smooth that curve. But crucial is our work on exports, and noble Lords will be interested to know that exports to non-EU markets of dairy products are up by 47% year on year.

The Earl of Shrewsbury: My Lords, is it not the case that one of the ways forward could be the model used by Tesco which has a margin-plus deal with farmers where at least farmers have an idea of what the future looks like and they get a decent price for their milk?

Lord De Mauley: Yes, my Lords. Certainly, innovative deals such as that are of real value to farmers. Sadly, not all farmers are able to negotiate those deals, but we are working with them, as I have said, on various ways to resolve the problem.

Lord Curry of Kirkharle: My Lords, as the Minister knows, I was at the summit yesterday hosted by his colleague George Eustice. While the long-term prospects for the dairy sector would appear to be good, what is also clear is that volatility is now an ongoing feature of global trading. I am concerned, as is the right reverend Prelate, about the long-term sustainability of the British dairy industry and the fact that we may lose market share. I understand that the Irish Government have introduced five-year tax averaging for businesses, which has existed in Denmark for a long time. Would the Minister consider approaching the Treasury to see whether that might be possible?

Lord De Mauley: My Lords, I am very happy to take that back.

Baroness Miller of Chilthorne Domer: My Lords—

Lord Berkeley: My Lords—

Baroness Miller of Chilthorne Domer: This side. This side.

Baroness Stowell of Beeston: Order. We need less of the shouting of “This side, this side” during Question Time. If we are going to follow the convention of sides, which is not the only convention we follow at Question Time, it is the turn of the Labour Benches, so we should hear from the noble Lord, Lord Berkeley.

Lord Berkeley: I am grateful to the noble Baroness. Does the Minister agree that one way of reducing the cost of production would be to introduce mega-dairies and very big units in the way that has been done for poultry and pigs? Does he have a view on that and what sort of size would the Government welcome?

Lord De Mauley: Certainly, my Lords, some producers are able to produce milk at a much lower rate—I met a farmer the other day who claimed to be producing milk in the mid-teens. We do not have strong views on the size of units of farms. What matters is stockmanship.

Baroness Miller of Chilthorne Domer: My Lords, does my noble friend agree that milk coming from grass-fed cows kept out of doors is of a superior nutritional quality? Further, will he say how important that is to the look of the countryside in all those areas dependent on tourism? Does he think that that would be answered by large industrial units?

Lord De Mauley: My Lords, there is a strong case for extensive farming. We see it in this country and some farmers are practising it very profitably. It depends to a large extent on the part of the country—on the rainfall, the quality of the grass and so forth. As I have said before, we think that there is a place for various different types of farming.

Lord Trees: My Lords, notwithstanding the voluntary codes by Tesco and so forth referred to earlier, which are to be commended, they apply only to a minority of dairy farmers. Is there not a case for extending the Groceries Code to primary producers of such vital products as milk? Most dairy farms are not protected under the code because they do not directly supply retailers; they supply processors.

Lord De Mauley: I have considered that point carefully, my Lords. The scope of the Groceries Code Adjudicator is based on a report from the Competition Commission, which found that the most significant problems in the area were experienced by direct suppliers to the UK’s 10 largest supermarkets. As a result, the Competition
	Commission recommended the creation of the GCA and limited its jurisdiction to the relationships between those 10 largest supermarkets and their direct suppliers. Any change to that would require primary legislation. It is a little premature to take the next step, because there is a mechanism in place for conducting a review and the first one of those is set for 31 March 2016.

Baroness O'Cathain: My Lords, the Question talks about the sustainability of the dairy industry. I am sure my noble friend is aware that the milk cheque is one of the most important ways of keeping agriculture going in this country. The number of dairy farmers has reduced from 30,000 about 15 years ago to 10,000 now. It seems that people are giving up. Can we impress this point on the Treasury, or whoever, and particularly on the retailers? Instead of having five private planes—in the case of one of our leading retailers—could not the retailers consider the future of agriculture in terms of the food supply to them in this country?

Lord De Mauley: My Lords, my noble friend, as always, puts her finger on a key part of the problem. I have outlined a number of measures that we are taking. I can also add to that the use of the RDP—the Rural Development Programme—to foster improvement of competitiveness and profitability, for example, by increased emphasis on value-added products, such as cheese and yoghurt. I think that is really important to our market. Once again I have to come back to you on the real importance of our work on exports.

Baroness McIntosh of Hudnall: Does the Minister agree that cash flow, which he touched on in an earlier answer, is a critical matter, both for farmers and co-operatives? Can he say whether he feels that the banks are playing their part in sustaining the farming industry by supporting them through volatility in cash flow?

Lord De Mauley: The noble Baroness is absolutely right. Cash flow is crucial. You can be as profitable as you like, but if you have no money in the bank, you cannot pay the bills. The noble Baroness is alluding to the cash-flow problems that face not only farmers but co-operatives. First Milk is a co-operative, wholly owned by farmers, and it is in the interests of farmers that it should survive and thrive. Work such as that being done by Dairy UK, which I referred to earlier, on helping farmers with cash flow is really important. Some of the banks are doing similar work.

Business of the House
	 — 
	Timing of Debates

Moved by Baroness Stowell of Beeston
	That the debates on the Motions in the names of Baroness Bakewell of Hardington Mandeville and Baroness Tyler of Enfield set down for today shall each be limited to 2½ hours.
	Motion agreed.

Natural Environment
	 — 
	Motion to Take Note

Moved by Baroness Bakewell of Hardington Mandeville
	That this House takes note of the natural environment and the case for reducing polluting emissions, improving green transport and protecting wildlife and green spaces.

Baroness Bakewell of Hardington Mandeville: My Lords, I am delighted to be able to lead the debate this morning. This is a very wide-ranging topic and one which can cause strong views to be taken on differing sides of the argument. However, the debate is really about planning for the future. How do we maintain our green environment for future generations and how do we put in place the infrastructure to make the best use of green technology as it becomes available?
	Some believe that the effects of climate change are with us. Others believe that it is all part of the natural cyclical process of the earth and can point to events in history which mirror our current predicaments. There are those taking part in the debate whose credentials are excellent and far outweigh my own interest in this matter. I look forward to hearing from them and also to the maiden speech of my noble friend Lord Callanan.
	On an almost weekly basis, we can see examples of global natural disasters on our television screens; whether excessive flood waters, extreme droughts or the melting of the Arctic polar ice cap. Last winter saw unprecedented rain falling on Britain, resulting in distressing floods in Somerset, on the land around the Thames and in many other areas. In 2010 the country suffered an extreme cold spell around Christmas, with large areas of the country under snow. Temperatures were recorded at RNAS Yeovilton of minus 17 degrees centigrade. During this period, despite the central heating and the Aga being left on, I suffered a burst pipe in the roof. Gallons of water descended through our cottage, bringing lath and plaster ceilings down and flooding the downstairs to a depth of three inches, so I have every sympathy with those who were flooded last winter. My saving grace was that the water in my home was clean and not foul, smelly and muddy water brought by rainwater flooding. We were in temporary accommodation for six months. Many of those flooded last winter are still out of their homes. I therefore have first-hand experience of the extreme effects of changes of weather.
	The Climate Change Act 2008 has shown the benefits of a clear legislative framework to meet the country’s carbon emission reduction target. I am delighted that my right honourable friend Ed Davey, the Secretary of State, has led the way on these issues. The green agenda has long been dear to the heart of Liberal Democrats, and we have plans in the next Parliament to take this further by setting legislative frameworks on five green laws.
	It is essential for the country to have a zero-carbon Britain Bill. This will toughen up climate change targets in the light of experience and be coupled with a global climate change treaty to ensure that the mechanisms are in place to meet targets. A nature Bill will introduce
	legal targets for biodiversity, clean air and clean water, and will establish a natural capital committee in law. The country must also move towards becoming a zero-waste Britain. It is essential to reuse all our scarce resources and create a circular economy. It is not enough just to talk about this; we need to set binding targets, with a clear action plan to reduce waste and end landfill. Our island must not be allowed to sink under the weight of the rubbish we produce. A green transport Bill will set clear targets for when we will see petrol and diesel-driven cars banned from using our roads and for rail electrification, as well as promoting cycling, walking and public transport. Other colleagues will talk about our green transport policies and no doubt share some excellent examples of good practice. An energy saving and renewable heat Bill will help to reduce energy bills by bringing in tough new energy efficiency standards and boosting renewable heat and district heating programmes. I shall give examples of this later in my speech.
	The zero-carbon Britain Bill will include a new legally binding target for zero-carbon Britain by 2050, to be monitored and audited by the Committee on Climate Change. It is also important that we look not just at measures to prevent climate change but at how we protect our natural environment, for example by establishing an office for accelerated low-carbon innovation to support the fast-tracking of less mature but key green technologies, including tidal and wave power, such as the Wave Hub off the coast of Cornwall, sponsored by the previous regional development agency. In addition, we should look at a renewable heat route to modern district heating, ultra-low emission vehicles, energy storage and CCS—carbon capture and storage—as well as continuing to apply emissions performance standards to existing coal plants from 2025 to guarantee that unabated coal generation ceases and to stimulate innovation in CCS. It will be important to extend full borrowing powers to the Green Investment Bank to boost further investment in low-carbon technologies.
	The nature Bill will include measures to identify those natural resources that we are harvesting at an unsustainable level, for example peat and wood. The peat industry has long been established in Somerset. Measures are already present to protect the environment, but these need strengthening to safeguard it for future generations. In order to protect the environment it will be necessary to increase the penalties for the enforcement and punishment of environment crime, such as deliberate water pollution, and wildlife crime. The proceeds from these increased penalties should be used to fund the National Wildlife Crime Unit and the sector of the Environment Agency which tackles pollution-related crime.
	Everyone enjoys the country’s forests and it is important to provide continued support for British forests by placing them in a trust to safeguard them against future potential sales. This is included in the coalition’s forthcoming draft forestry Bill.
	Green accessible spaces are much valued by local communities and introducing a new designation of national nature parks is one way of protecting this valuable asset for future generations. The right to roam is similarly valued by residents; thus including
	the national forests and other publicly owned land, while examining the viability of opening up inaccessible habitats that are in private ownership, is also key to the nature Bill. It is important to examine how we put in place the infrastructure we need to build a low-carbon, green future.
	I turn to the zero-waste Britain Bill. In south Somerset we are proud of our recycling collections. Waste lorries come every week to collect separated, recyclable plastic, cardboard, glass, tin and foil. Putrescent waste is also collected weekly to go to on-farm composting. The residual waste is collected fortnightly. The vast majority of residents are happy with the arrangement and know they are contributing to reducing landfill. Nevertheless, this is a drop in the ocean and it will be necessary to do more countrywide. We will commission a Stern report on reducing the UK’s consumption of natural resources in order to facilitate the circular economy, facilitating waste minimisation and ensuring that only non-recyclable waste is incinerated. We will also argue for faster development of EU sustainable design and production standards. Coupled with this, the banning of biodegradable waste from landfill by 2020 will be key.
	As the House already knows, we will bring in the 5p plastic bag charge announced in this Parliament. Consumers will pay for each new single-use plastic carrier bag they use at the point of sale. After administrative costs have been met, the supermarkets will donate the remaining money to charity. We will scrap all the exemptions, such as for SMEs and paper, associated with this ban.
	I turn finally to an energy saving and renewable heat Bill which invests in the future. Measures included in this Bill will be low-carbon infrastructure investment in, for example, heat networks, energy storage systems, hydrogen distribution and carbon disposal systems. These will be classified as utilities for infrastructure development purposes. A new legal framework will be set up to require all relevant regulators to facilitate the development of deep geothermal heat, large-scale heat pumps and waste industrial heat and energy storage systems. Ofgem’s remit and powers will be revised to enable it to regulate all heat forms and heat networks so that it can provide, for example, protections for heat network and heating oil customers. There will be new efficiency incentives to help people cut their energy bills permanently. For example, the vast majority will be able to cut their council tax bill when they invest in energy-saving home improvements.
	I am sure that many of your Lordships live in areas where there are listed properties, some with thatched roofs and mullioned windows. It is extremely difficult for home owners or landlords of such properties to improve their energy efficiency without putting in double-glazing and others measures not permitted by conservation officers. Does the Minister have any solutions to offer for these properties?
	New energy efficiency regulations will come into place, for example when people make certain home improvements requiring planning permission. They must also include energy-saving improvements and new higher energy-efficiency standards within building regulations for lighting, motors and cooling and ventilation
	products. In addition, new heat-saving regulations will apply. For example, when people change their heating system, other low-cost heat-saving investment would become mandatory.
	Ensuring that everyone, including those on very low incomes, is helped to reduce their energy costs is essential. There will be new, long-term legal targets for assisting domestic homes, starting with social housing and then moving to privately rented and then owner-occupier homes. In the south Somerset area, the housing providers already take steps to ensure that their homes are energy efficient, both as new build and as retrofit. They know that if their tenants are able to reduce energy bills they are more likely to be able to afford rent, buy food and live fulfilled lives. It is important that we have flexibility in all things. On zero-carbon housing, if a developer is not able to make a home fit the zero-carbon standard, does the Minister agree that allowable solutions should include an obligation to retrofit another house?
	The coalition Government have already set out that fuel-poor homes would have to meet the band C minimum standard by 2030 regardless of tenure, with relevant government and industry subsidy and support. We are currently consulting on setting a standard for privately rented homes for 2018 and beyond. Liberal Democrats would propose that this standard should be band C by 2030. We would also consult on setting a standard of band C for social homes by 2025. The clear aspiration would be for owner-occupier homes to be band C by 2035. In all cases the standard would, as far as reasonably practicable, be subject to testing—your Lordships would expect nothing less—as it is recognised that some homes cannot be brought up to band C at a reasonable cost.
	I am pleased to be able to report that, earlier this week, Wiltshire Council passed a motion proposed by Liberal Democrat councillors to reduce energy consumption by creating a Wiltshire energy efficiency board, with the remit to work with partners across the county to develop a joint strategy to achieve increased energy savings, and the consequential economic savings to match, and then to exceed the south-west average. The motion was supported locally by my colleague Duncan Hames MP from the other place.
	I am also pleased to be able to tell the House about an energy society which has been set up in south Somerset—the south Somerset energy society. It is in embryonic form but is applying for a rural community energy grant to start its feasibility study. This society, working on a similar model to that used by the Plymouth energy society, hopes to raise share capital for its investments in businesses, schools and community facilities to enable it to access cheaper energy. I am sure that there are many similar examples throughout the country of local initiatives striving to cut energy costs. I look forward to the contributions of other noble Lords, and I beg to move.

The Earl of Selborne: My Lords, the whole House will be grateful to my noble friend Lady Bakewell of Hardington Mandeville for giving us an opportunity to hold what I predict will be a wide-ranging debate on
	the natural environment. I would like to look at the implications of environmental change in the widest sense, not just climate change, remembering of course that the United Kingdom’s natural environment is the product of centuries of management. Whether it is agricultural land, woodland, forest, heaths, moors, coasts, green spaces or urban areas, all are products of our management. The only area of wilderness in the United Kingdom is perhaps the flow country of Caithness and Sutherland, an area of blanket bog. If we look at the steady loss of biodiversity in most habitats, it is evident that we have much to do to stabilise wildlife populations.
	Increasingly, we are recognising the importance of protecting ecosystem services on which we ultimately depend, whether for food production, flood prevention, pollination of crops, air purification, raw materials recycling and much else. The United Kingdom National Ecosystem Assessment was carried out between mid-2009 and early 2011. It was the first analysis of the United Kingdom’s natural environment in terms of the benefits that it provides to society and its continuing prosperity. This assessment should set the agenda for future consideration as to how we monitor, conserve and enhance ecosystem services.
	A particularly interesting issue, although it is difficult to grapple with, is the extent to which we rely on or could benefit from the correlation between human health and the environment. It is a statement of the obvious to say that we benefit from a contact with nature, but it is not easy to measure the relationship between green space and the health of population levels. Here, if anywhere, is an area where much more research is needed on the positive aspects. There is much research on the negative consequences: t is easy to demonstrate that degraded and contaminated environments impact adversely on our health, particularly our mental health.
	Another aspect that states the obvious and of which we are all well aware is that since the Second World War there has been a dramatic change in United Kingdom land use. It is because our national priorities changed with the intensification of agriculture, urbanisation and transport development. Some 90% of semi-natural vegetation has been converted to arable use. You cannot change the use of land without dramatic and major impacts on ecosystems, and therefore the delivery of ecosystem services. Unless you are very careful you will cause the disruption of flood regimes, river basins and coastal wetlands. These are the issues with which we must deal. They are related not just to climate change but also to land use and the impacts of an expanding economy, which of course we welcome.
	It is easy to cast gloom and doom over the natural environment, but we should also remember some positive aspects during the period since the war, about which I have been talking. There are the Clean Air Act 1956, the Wildlife and Countryside Act 1981, and EU directives such as the 1979 birds directive and 1992 habitats directive. These have all played an important role in helping us to take our responsibilities more seriously and with a degree of continuity.
	In reference to the Clear Air Act, while cleaner air can be described as a success story, it remains at the regional level a serious issue, especially in urban areas. Ambient air quality has improved but diffuse sources of atmospheric pollution remain a challenge. As our Motion today identifies, transport is a major source of pollutants, as are power generation and industrial emissions. Air quality needs to go up the environmental agenda. The Government could lead the way in raising the priority attached to air quality in all government departments. In another place the Environmental Audit Committee calculated that poor air quality will reduce average life expectancy in this country by an average of seven to eight months, and that up to 50,000 people a year may die prematurely because of poor air quality.
	On our record on national biodiversity loss, there is good news. Some species have done really rather well. There is the reintroduction of the red kite, a bird with which we are now all familiar; at one time, it was isolated in Wales. There are also buzzards, deer, badgers, otters and some non-specialist butterflies, for example. They have all expanded their range. These tend to be generalist species. The specialist species have done far less well. Since 1995, 70% of butterfly species, 50% of bird species and 28% of plant species have declined in abundance. Those are sobering figures and need to be considered against a background of some over-optimistic targets to which we have signed up, at national and international levels. As a result of the Earth Summit in Rio de Janeiro, we became a signatory to the Convention on Biological Diversity. There were also Millennium Development Goal 7.B and the EU targets for 2010. All have been a history of failure to meet targets. They had good intentions, but without thinking through how we might reduce our impacts we will never meet these targets. At present we are signed up to the Aichi targets, which were set in Japan, for 2020, but it would be a brave person who predicted that we were going to meet them.
	The key to this will be when we ultimately work out how we determine the ownership and distribution of property rights for natural capital assets, which is a highly contentious issue but one on which the Natural Capital Committee, which provides advice to government on the state of England's natural capital, is giving advice. If we could get into our national consciousness and the balance sheets of each and every company in the country an assessment of what impact for better or worse they are making on our natural capital, it would be something of a game-changer. There would be lasting benefits to the United Kingdom if we could demonstrate the value to society of our natural capital and reward those who protect and enhance the desired ecosystem services. This does not have to be done with new subsidies or grants from government; it can be done by adjusting the tax system to reward those who are looking after future generations.
	I return to transport, which is mentioned in the Motion. My second game-changer would be to look at the development of hydrogen. We are already there: we have cars, buses and boats fuelled by hydrogen. The problem is, of course, the high cost of fuel cells and the absence of a refuelling infrastructure. The Government recently announced an £11 million investment in United Kingdom hydrogen vehicle infrastructure and £2 million
	of funding for public sector hydrogen vehicles. I think it is quite realistic to think that in 10 years’ time hydrogen will be competitive in price with petrol and diesel. It will certainly reduce pollutants in the air and, provided the electricity which produces the hydrogen is from renewable sources, it will make a contribution to a reduction in greenhouse gases. There is a challenge: if in the run-up to the general election any political party can commit itself to travel only by hydrogen-fuelled vehicles, it will be doing us a service.

Lord Whitty: My Lords, I, too, thank the noble Baroness for initiating this very wide-ranging debate. I thank her also for giving us a quick preview of what would be the Queen’s Speech of a Liberal Democrat Government—some of which sounds vaguely attractive, and I might support it.
	The title of this debate ranges from the very local to the international, and we do not know where to begin. The noble Baroness began, as I rather suspected she might, with the situation in Somerset and the Somerset levels and the disastrous, distressful floods. There was a terrible impact on both the people there and the environment. However, as the noble Earl, Lord Selborne, said, the key thing about the Somerset levels is that they are not, in a strict sense, a natural environment. They have been created by manmade measures over the centuries: intricate water management, successive different forms of farming putting pressure on the system, deforestation, local pollarding of trees and so forth, and ever-changing farming practices. They all put pressure on the system. All those efforts gave an economic base to the area and the landscape that we love, but the levels are not a natural environment. They need to be protected, but we need a different system of human management for such areas.
	The storms of last year which caused the floods in Somerset and elsewhere were a unique event and were unprecedented in their form. While one cannot ascribe any individual extreme weather event to climate change, climate change means that we are going to get more of them. The likelihood is therefore that the UK and the world will face greater storms, floods, droughts and other disasters, and we need human management to deal with that. In order to protect our environment, we need a change in intervention. As in 19th century Sicily, unless there is change, things cannot remain the same. We therefore need to recognise that the challenge of global climate change will mean a lot of new, local interventions. I do not want to be too despondent, but the world has largely failed on climate change. The conference in Paris this year may be the last-chance saloon to stop average global temperatures going over the 2% level.
	There are some fairly worrying indications. The fall in the oil price means that people and markets are switching back to fossil fuels. The development of shale gas and shale oil has displaced coal in America. On balance, this is a positive thing, but it has reduced the price of coal, which is being exported to markets at a low cost, as is US oil. The net result is that the price of fossil fuels, relative to nuclear and renewables, is changing. The problem is not just in places like China, where coal-fired power stations are coming on stream
	every month, or India where the explicit objective of the new Government’s policy is to exploit to the full India’s domestic coal resources—most of which are lignite, the worst form of coal. It is also true within Europe, where Polish and German lignite is now being used to a greater degree: even green Germany is opening new coal-fired power stations.
	In aggregate, the global subsidies for coal far outweigh those for renewables or nuclear energy. The markets and, in some cases, government policy, are moving in the wrong direction. Over the years, the UK Government have, commendably, taken the lead in both establishing targets and introducing policies designed to offset this. However, most of those policies have not delivered to the extent that they should. The noble Baroness mentioned issues of energy efficiency in residential and other property, but so far the measures are faltering. The ECO is not working as it should, nor is the Green Deal, and take-up of the RHI is very limited. A report which I was partly responsible for found that there are very few pressures in the commercial and industrial sectors for increasing the environmental efficiency—and therefore the energy use—of commercial buildings, old and new.
	As the noble Baroness said, we need intensified policies in all of these areas. We also need them on land management: how we use land and water. We need to plant more, appropriate trees on many of our hillsides; we need more effective water management by catchment; we need to reform the abstraction regime for water in our uplands. We cannot defer this, as we have done for many years. Some of these interventions, and some on the energy side, will be seen by some as detrimental to the natural environment, but that will only be in the short term. In the long term, they will protect our natural environment.
	I am not saying that we should give up trying to mitigate the rise in carbon and greenhouse gas emissions. That objective is still there, but we need to recognise that a significant rise in global temperatures—probably over two degrees—is now almost inevitable. We therefore need to look at adaptation in the way that we have looked at attempts to mitigate. On the mitigation side, the Climate Change Committee has indicated that the next Budget will require us to cut, between now and 2025, by another 28%. We succeeded in meeting the first budget targets only because of the recession. The underlying change is nowhere near close to achieving those ends. That means that even in the UK—which is leading in this area—we are not likely to make our contribution to reducing carbon.
	We therefore need to focus as well on mitigation. That will need capital expenditure by both public and private sectors. We know that the way in which projects are assessed in the private sector tends to focus on the short term. We know that the immediate fiscal problem with regard to public expenditure is limiting the amount of public investment in things such as flood defence, resilience of infrastructure and the whole area of protection of our countryside. Unless we put the money in and give some priority to that form of investment, we will neither protect what we call our natural environment nor avoid the major problems that are facing us through the process of climate change.

Baroness Miller of Chilthorne Domer: My Lords, my noble friend, whom I congratulate on securing this debate, outlined the proposed nature Bill in her admirably comprehensive introduction. I shall concentrate my remarks on green space, which, as the noble Lord, Lord Whitty, pointed out, is not necessarily a natural environment as we might have found 2,000 years ago—that exists probably nowhere in the UK. There are wilderness areas or wilder areas, as in the national parks, but much green space is what we share with other species. With the decline in biodiversity that has tracked the whole of my lifetime, through the 20th century, there has been an increasing pressure on all the places where other species lived, to the point when they often ended up with nowhere to live and breed.
	Successive Governments this century have made some very good efforts, and I commend the Labour Government, when the noble Lord, Lord Whitty, was a Minister, for the Countryside and Rights of Way Act, because there is nothing like getting the public involved in being a major part of the protection of green spaces. One of the major steps for this Government was the report from John Lawton, Making Space for Nature, which talked about protecting what we have, the SSSIs and the EU habitats, which of course we are obliged to protect. In mentioning the EU habitats, I say to noble Lords who are Eurosceptics that without the EU’s input into areas such as water pollution and protection of species we would be in a much worse place than we are in now. The EU can claim enormous credit for turning around what was a pretty grim picture in the 1960s and 1970s.
	We should expand and join up these spaces for nature with wildlife corridors. That was Sir John Lawton’s contention. The babies that came out of that report were the nature improvement areas, of which there are currently 12—and that is a start. In their assessment of 2013, the Government found that each pound invested by the Government results in nearly £6.80 of additional support from communities, businesses and individuals. It is actually very good value. However, there is still a tremendous amount more that can be done. One area that has been overlooked until now is local wildlife sites, which are important havens, identified and selected locally for their high-nature conservation value and with great public support from the people on whose doorsteps they are. The Wildlife Trusts, which I must commend for their work, because their mission is to connect the public with wildlife and to protect that wildlife, produced a report entitled, Secret Spaces: the Status of Local Wildlife Sites 2014. It found enormous pressures on those sites. It may surprise your Lordships to know that, although they are recognised within the planning system, local wildlife sites are not protected by law. That was one of the recommendations—that greater protection should be given to them—that Professor Sir John Lawton came out with. It would be one thing at the top of my list of things to be done.
	Of course, we have had lots of strategies beyond the ones that I have mentioned. We had a biodiversity strategy from Defra in 2011 and the important natural environment White Paper, as well as the work on eco- systems services, all of which are important contributions.
	However, I would agree that putting the work of the Natural Capital Committee on a statutory basis is one of the most important steps that we can take now, because its work values the synergies that we find between, for example, farming benefiting wildlife, clean water and more absorbent soil, as well as more interesting landscapes. We have found that there are lots of indicators of the health of an ecosystem: pollinators, for example, which is an issue that we have debated in your Lordships’ Chamber before, frogs and farmland birds. The Government are committed to reversing the long-term decline in the UK farmland bird indicator, which is made up of 19 species. Noble Lords will be aware of the different reasons for that decline, particularly different farming methods.
	I would particularly like to mention one initiative from LEAF—Linking Environment and Farming—that is important in helping to reverse this decline. It is starting its big farmland bird count within the next month and will involve farmers. It is looking at what can be achieved by the adoption of simple management techniques to improve habitats and bird numbers and includes information on bird identification, because it is not a given that every land manager can identify all the species. There is much work to be done. The mistle thrush and the yellowhammer have declined enormously since the 1970s here in England, but oddly in Scotland, that decline has now reversed and the populations are becoming much healthier. Perhaps there is something that we can learn from Scotland.
	To conclude, I would like to talk about bats, which are the subject of a Private Member’s Bill in the other place on Friday of this week. The Bat Habitats Regulation Bill is sadly geared toward preventing bats from living in churches. There have been many claims that bats are contributing to a health hazard—which Public Health England denies—but why do bats need special protection in the first place? It is easy to kill a whole roost of bats, and people have often had a prejudice against them. They, perhaps more than any other species, have suffered from declining habitats, with barn conversions and so on. The Bill, which perhaps will come before your Lordships’ House, refers to enhancing the protection available for bat habitats in the non-built environment. That is all very well, but then it refers to limiting the protection available for bat habitats in the built environment,
	“located inside a building used for public worship”.
	That is a very dangerous precedent. Anyone who does not like bats can claim that people are gathering to worship. I hope the right reverend Prelate will take this up, as I think it is a very sad comment on the churches’ attitude towards wildlife. There is a simple solution: if bat faeces are falling in an embarrassing place, you simply need to nail a board under that, as many people have learnt to do in their own homes.

Lord Callanan: (Maiden Speech) My Lords, I join in the congratulations to the noble Baroness, Lady Bakewell, on securing this debate today on such an important subject, giving me the opportunity to make my maiden contribution to the debates in this House. I begin by thanking noble Lords on all sides
	for being so helpful and welcoming, and for so politely pointing out my many mistakes so far, the most serious of which was rising to leave the Chamber when the Lord Speaker was on her feet. I shall not be doing that again.
	Let me particularly thank my two sponsors, my noble friends Lord Bates and Lord Inglewood. I first met my noble friend Lord Bates 30 years ago; we both attended the same Gateshead comprehensive school and joined Gateshead Young Conservatives at about the same time. I do not know what prompted him to do so: Gateshead was hardly then, or even now, a hotbed of Conservatism; but in my case, the late Lady Thatcher was entirely responsible for my decision to join the party. I am profoundly sorry that I never had the privilege of serving in this House alongside her. After that, the political careers of my noble friend Lord Bates and I went in different directions. I served on Tyne and Wear County Council, Gateshead Council and then in the European Parliament; he, of course, served in the other place. I am also grateful to him for one other thing—for leaving the title of our home ward, Low Fell, for me to take.
	I was proud to represent the north-east of England in the European Parliament for 15 years, where for part of that time I also served alongside my noble friend Lord Inglewood, who represented the north-west. We often travelled to Brussels and Strasbourg together and spent many a happy hour debating the latest political scandals in the departure lounge of Newcastle Airport.
	In the European Parliament our speeches are often time-limited to two minutes, or sometimes even one, so I am delighted to be in a Parliament where one sometimes gets the opportunity to speak for what seems like an eternity of eight minutes. I sincerely hope that noble Lords will not wish, at the end of my contribution, that I had spoken for only one minute. Another great advantage of this House is that all the debates are—ostensibly, at least—in the same language.
	Turning to the subject of today’s debate, for most of my time in the European Parliament I served as Conservative environment spokesman and worked on many of the emissions and climate change directives, including the Euro 5 and Euro 6 engine standards and the emissions trading system in all its many complicated incarnations. I know that a maiden speech is not the time to burden your Lordships with some of the complicated detail of such directives, so I will merely say that I always took the view that our environmental ambition should not be achieved at the expense of damaging the competitiveness of some of our excellent British and European manufacturing industries.
	I am fortunate to come from the north-east, a part of England with many economic difficulties, but also blessed with some of the most beautiful countryside and magnificent natural environments in our nation. I sincerely hope to use my time in this House to contribute in some small way to help to resolve the former and to sustain the latter.

Lord Bradshaw: My Lords, we were very glad to hear from the noble Lord, Lord Callanan. He brings two things with him. First, he is an engineer.
	Both Houses of Parliament are woefully short of people with technical knowledge in the various engineering fields. Secondly, he comes from the north-east. One has only to sit and listen to recent introductions to notice how many come from Greater London. This House is very short of people who have a regional perspective on things. To this particular House he brings a third quality: he must feel a lot younger than he did before he came here, being surrounded by so many more mature people.
	I will concentrate my remarks on two or three things. First is the question of emissions. Emissions in town and city centres concern me greatly. A lot of work is being done on the Euro 5 and Euro 6 engines, to which the noble Lord, Lord Callanan, referred. However, a great deal of the pollution in our towns and cities comes from the refrigeration and cooling units on lorries that deliver food and other perishables to shops and airports. These refrigeration engines, which are diesel-powered, do not have the means to send their exhaust through the exhaust cleaning system of the engine. You might clean up the engine that is propelling the lorry, but you have an extremely polluting cooling system attached.
	I am aware from a letter I received from the Minister this morning that there is work going on in Europe on non-road mobile machinery mechanisms, but there is a solution to the problem I have outlined. It is to use compressed air or compressed nitrogen engines to run the cooling units that are so prevalent in the traffic of today. The plethora of delivery vehicles running round from various shops, delivering goods to your home, is all very well but the vehicles bring a lot of pollution with them and this is scarcely recognised. Can the Minister say whether this non-road mobile machinery includes supplementary engines mounted on the road vehicles? I am not sure that it does. The happier news is that there is a technical solution. It is a British solution that has been developed and is going through, I think, the advanced stage of trails. If it is adopted—I am not an engineer and cannot comment on the technology—it will make a huge contribution to cleaning up the air in cities. I know there is debate about the effects of climate change but there is no debate about the health hazards of vehicle emissions.
	The second thing I would like to ask the Minister concerns low emission zones. There are low emission zones in a few places and I have noticed that the Mayor of London intends to make the City—or the whole of London, actually—a low emission zone by 2020. It is important to give people fair warning of these things. Up to a few years ago, they had been encouraged to buy diesel cars. Suddenly to reverse that and say that these cars will now be prohibited is very hard, but if you give notice people can adjust. They sell and buy cars and adjustments can be made, as they have had to be made to buses. I have been involved in the bus industry, as I think is fairly well known.
	I put this point and to some extent I turn to the remarks of the noble Lord, Lord Callanan, about the competitiveness of British industry. There is a lack of inventiveness and a lack of capacity to ensure that good ideas are developed here and exported around the world because they are seen to be necessary and
	good value. The point about stimulating research, innovation and development here is one that I have heard echoed round this Chamber on many occasions, but it is absolutely important for industries in the area from which the noble Lord, Lord Callanan, comes.
	I will not keep noble Lords any longer but I will be pleased to give the Minister the information I have on air engines, and I would be glad to send it to anybody else who is interested.

Lord Framlingham: My Lords, I add my congratulations to the noble Lord, Lord Callanan, on his excellent maiden speech and I am sure we look forward to further contributions from him.
	I am extremely grateful to the noble Baroness, Lady Bakewell, for obtaining this debate today which allows me to talk about one of my favourite topics: trees, particularly ones in urban areas in what are currently called hard landscapes. Trees are like the humble bee. They do a massive job in the environment and are taken for granted by most people, yet without them our very survival would be threatened. I remind you what an incredible job trees do. They look attractive. They take in our waste carbon dioxide and give us in return precious oxygen. They provide shelter and are barriers to both pollution and noise. They help to cool the urban environment and manage storm-water run-off. They have been shown to have a positive effect on the nation’s health. In short, they are quite simply indispensible.
	Yet the question that I want to pose is: are we making the most of this incredible asset? We use trees to adorn and enhance our finest buildings and to hide and camouflage our ugliest. When applying for planning permission, architects embellish their drawings with pictures of mature trees, yet so often, when the development takes place, for reasons of finance or inadequate aftercare the trees as envisaged never appear.
	It must be obvious from what I have said already that what is needed is a nationally co-ordinated approach to the design and management of hard landscapes. This would ensure the maximum and most imaginative use of trees and guarantee both their planting and their aftercare—to decide not just what type of tree to plant but to take into consideration its ultimate size, crown spread, root spread, disease resistance, the soil type in which it will flourish and its proximity to underground utilities, as well as things such as its leaf drop, fruit production and aftercare needs, and 1,001 other issues.
	Clearly the Government have a role to play in this, although I am not quite sure which department it currently comes under. However, help is also at hand in the form of an organisation called TDAG, the Trees and Design Action Group. This organisation, now a charity, was formed in 2007 with the ambition to create a very broad network of expertise across the built and natural environment, sharing a common understanding that trees have a major role to play in the health of our cities.
	Perhaps I should declare an interest—one that is not in any way financial. Many years ago, I was for some time the president of the Arboricultural Association,
	which is a member of TDAG. The group contains the widest possible spectrum of organisations concerned with these issues, from local authorities to landscape architects, from civil engineers to nurserymen, and from banks to the Forestry Commission—too many to mention but all with the same aim: to get more healthy trees in our cities and thus improve the health of those who live there.
	TDAG has produced two excellent publications: Trees in the Townscape and, last October, Trees in Hard Landscapes: A Guide for Delivery, which I am sure the Minister will be aware of, since his colleague, the noble Baroness, Lady Kramer, wrote the foreword for it. I urge him, if he is not already doing so, to lend his weight to the distribution of these guides, or more particularly their contents, so as to co-ordinate and encourage the most enlightened and best practice everywhere.
	We must use all the experience available to us, together with our imaginations, to break new ground and to break out of our sometimes routine thought processes. Many years ago on a lecture tour in the United States, I found myself in Philadelphia. In those days, Ginkgo biloba, the maidenhair tree, was relatively rare in the United Kingdom. To my astonishment, in Philadelphia it was used as a street tree. It was everywhere. If it was an ideal street tree there, why not here? That is a lesson I have never forgotten. I believe it is now called “thinking outside the box”.
	It is not just housing, office or town-centre develop- ments that present challenges and opportunities. What about business parks, industrial sites, motorway and railway embankments, and roundabouts? Opportunities abound not always with big trees but sometimes with small trees, shrubs and low-maintenance ground cover, but always with a mixture of experience and imagination to produce the best possible use of the ground available for the maximum effect.
	I should like to deal briefly with two other important topics: tree importation and woodland protection. Following the importation of ash dieback from Europe, there was a call, including one from me, for a reduction in the number of imported trees and for much more reliance on home-grown stock to reduce the ever present and very real danger to our tree population. Sadly, figures that I obtained through a Written Question show that in the last planting season we imported more trees than ever. I acknowledge that this is not a simple matter. It involves long-term planning, with appropriate commitments and contracts. But trees are a long-term business, and getting it wrong again would be disastrous.
	Perhaps a quarantine system is the answer, at least in the short term. A company called Barcham Trees, based in East Anglia, has introduced its own quarantine system. It says that it will not import trees and sell to customers for immediate planting, and that,
	“All imported trees will be held on the nursery for one full growing season during which time they will be subjected to rigorous inspection for pest and disease. This includes systematic and regular DEFRA visits”.
	I do not know whether other companies are doing this, but if it is not already happening, perhaps the Minister could look into the merits of that system. Audit trails for trees are also important, so that trees sold by any particular nursery can be easily traced.
	Caring for existing trees is vital, not just in urban areas but in woodlands too, particularly ancient woodlands. Houses can be demolished and rebuilt in a matter of months, but an invaluable ancient woodland, if lost, is lost for ever. The Woodland Trust tells me that it is currently fighting 400 cases where woodlands are under threat. I know the Minister has a great interest in woodland, and I urge him to do all he can to preserve it wherever possible.
	We must care for all our trees, old and new. I would say to the Minister, who I am sure loves his trees, “Don’t listen to those who say you never see the results of tree planting in your lifetime”. Trees make their presence felt in a few short years, and what better legacy could a Minister leave than to have significantly increased the nation’s tree cover, particularly in our towns and cities?

Lord Greaves: My Lords, I, too, thank my noble friend Lady Bakewell of Hardington Mandeville for introducing this debate and setting out so eloquently the nature of a nature Bill, which the Liberal Democrats would like to introduce in the next Parliament. I look forward to working closely with the noble Lord, Lord Whitty, when that Bill comes forward. I should remind the House of my registered interests as a councillor and as an active member of various access organisations.
	I shall talk first about the “natural environment” part of the Motion, and particularly about access to the natural environment. In the nearly 15 years for which I have been a Member of your Lordships’ House, the number of occasions on which we as a House have contributed to the extension of people’s ability to access the natural environment has been a great pleasure to me. The very first Bill that I was really involved with was the Countryside and Rights of Way Bill in 2000, for which the noble Lord, Lord Whitty, was responsible in this House. That set a pattern that we have followed since.
	However, there is now a real threat to vital countryside and rights of way services—the access services provided by local authorities—as a result of the cuts, many of them drastic, that local authorities are having to cope with. Many of them see the rights of way staff and services as not being part of their core service. This really began to bite last year, when some authorities were even proposing to close down the service altogether. I do not think that they can do that, because it is a statutory service, but many authorities are subjecting their services to cuts. We do not know yet what will be the effect of the current round of local authority budget making for 2015-16, but it seems that further cutbacks in many areas are inevitable.
	Some of the more flexible, and perhaps enlightened, authorities have been able to make a link with the new health and well-being boards and their public health functions, and use a certain amount of public health money for the promotion and support of active outdoor recreation. Clearly, that is to be welcomed. But the pressures are everywhere. In my own local authority of Pendle in Lancashire, we have one of the densest networks of public footpaths in the country, which are vital to tourism, local recreation and the health of the
	local population. Because we have been able to maintain an agency service where the district council carries out the rights of way service on behalf of the county council, with subsidy from the county council but topped up by the district council, we have the highest standard of service in the county and our paths are in the best condition of any in the county. But the county council, like all other local authorities, has been under pressure and put forward a proposal to stop the agency and significantly reduce the service. We had some fairly vigorous and interesting discussions and I am pleased to say that we came to a compromise. We have been able to fight off the idea that because our footpaths are in the best condition of any in the county we do not need to do much to them for the next few years—until, presumably, they get back to the mediocre standard of other areas.
	This is the kind of debate that is happening on so many services in local government at the moment, and the rights of way service is not in any way immune. I want to ask the Minister a question, which I am sure he will not be able to answer today, but perhaps he can dig out what information the Government have and write to me and other Members. What impact have the cuts already had on rights of way and countryside access services throughout England? Do the Government know what the situation is so far, to provide a baseline from which to go forward?
	The second area I want to talk about is referred to in my noble friend’s Motion as “protecting green spaces”. I particularly want to talk about urban green spaces. The promotion of new urban green spaces is something for which the Liberal Democrats, in particular, have been pressing for a number of years. The proposal for a new designation under the planning system first appeared in the Liberal Democrat manifesto at the last general election. That led to a number of references to urban green spaces in the coalition agreement, a copy of which I have with me. It is an historic document that no one seems to pay much attention to any more, which is an interesting lesson for the future. Coalition agreements at the beginning of a five-year Parliament are regarded as being extremely important for a while, fairly important for two or three years, and then forgotten.
	I have a copy of the agreement, which is still on various websites, including the government website. Under the heading, “Environment, food and rural affairs”, the coalition agreement states:
	“We will introduce measures to protect wildlife and promote green spaces and wildlife corridors in order to halt the loss of habitats and restore biodiversity”.
	Under the section on “Communities and local government”, it says:
	“We will maintain the Green Belt, Sites of Special Scientific Interest … and other environmental protections, and create a new designation—similar to SSSIs—to protect green areas of particular importance to local communities”.
	The results of this appear in paragraph 76 of the National Planning Policy Framework, which is a document that people pay rather more attention to nowadays than they do to the coalition agreement. It states:
	“Local communities through local and neighbourhood plans should be able to identify for special protection green areas of particular importance to them. By designating land as Local Green Space local communities will be able to rule out new development
	other than in very special circumstances. Identifying land as Local Green Space should therefore be consistent with the local planning of sustainable development and complement investment in sufficient homes, jobs and other essential services. Local Green Spaces should only be designated when a plan is prepared or reviewed, and be capable of enduring beyond the end of the plan period”.
	It was clearly intended that these new local green spaces should be an important part of the planning system.
	I have another question which the Minister will not be able to answer today, but perhaps the Government can tell us what information they have. To what extent is this actually happening in all the local plans that local authorities have been producing and taking to inspection and adoption within the past two or three years? I have a sense that this has been a bit of a damp squib in many cases and that local authorities have not really grasped this new ability to, in effect, declare new parkland in parts of their areas, particularly their urban areas. This is something that our party will want to continue to stress and to press for and perhaps give greater prominence to in future. I have run out of time so I will say no more.

Lord Borwick: My Lords, I declare my interests as they appear in the register, particularly that I am a trustee of the British Lung Foundation. I welcome this debate, as all too often the push to reduce emissions and improve our green spaces means that we spend a lot of money on the wrong things. The result is more regulations and higher taxes, which push up the cost of living. The hardest hit are often the poor and the elderly, who spend more of their incomes on electricity and gas. Indeed, taxes can make up 15% to 20% of the cost of power to a household. If we are trying to reduce emissions and improve air quality, we have to think of other ways of doing it than imposing new or higher taxes.
	However, none of those points detracts from the fact that we need to reduce emissions, improve green spaces, protect wildlife and think about how we travel in the future. It is very important that Parliament stays ahead of changes and developments in this issue. That is why I have proposed to the Chairman of Committees the creation of an ad hoc committee on air pollution. From the great stink of 1858 to the great smog of 1952, population growth and industrialisation have reduced the quality of the air in the UK, especially in big cities. The Clean Air Act 1956 was perhaps the earliest significant attempt to enshrine in law the protection of air quality. Now that science is delivering more local knowledge on air pollution, we have to be aware and preparing for the pressures that that will bring.
	Within a short time, we will be able to get a smartphone app to tell us the levels of air pollution within a local area, measured from space. This means that your sat-nav directions might include the option of the quickest route, the shortest route and, in the future, the cleanest route. When citizens get the knowledge that their home area has bad air pollution, they are going to demand that the Government do something about it. Individuals tend to think—probably rightly—that they cannot improve air quality through their own actions alone. The same can arguably be said for government departments. That is why it is vital that collaborative
	work is done on this problem across government. The Department of Energy and Climate Change is, of course, interested in climate change but not sufficiently in emissions. The Department for Environment, Food and Rural Affairs, the Department of Health, the Department for Transport, the Department for Business, Innovation and Skills and the Department for Education are all responsible in part for emissions.
	Lung diseases are strongly correlated with poverty. There are rich people who die of lung diseases, but they die mainly of heart problems. It is poorer people who smoke too much and live in areas where they suffer from bad air quality—and many from tuberculosis. The climate change problem has been regarded as so important that we put every effort into reducing CO2 emissions. Many car manufacturers switched to diesel in whole or in part, and we now have extra nitric oxide and nitrogen dioxide in the air. Perhaps it is fair to say that Britain is doing quite well on global warming, better than the world generally, but are more people going to die of lung poisoning as a result of some of those changes?
	So, the level of emissions in the UK is having a very harmful effect on both the environment and on human health. While much is known about CO2 and its impact on the environment, there is far less awareness of the harm to public health caused by particulate matter in the air. Exposure to these poisonous particulates can lead to inflammation of the airways, and cardiovascular and respiratory illness. In April 2014, a Public Health England report found that approximately 29,000 deaths per year in the UK could be attributed to man-made particulate matter pollution. Air pollution is also expected to reduce the life expectancy of everyone in the UK by six months.
	We know that the noxious villain of NOx is the car exhaust, and what do we do with our car exhausts? We cover them in shiny plating to make them look attractive and stick them out the back of the car, where the pedestrian or cyclist can breathe the fumes. There is an old-established saying in management that if you do not look at a problem, you will not solve it, and we place the exhaust in the one place that the driver can never see directly, so he cannot tell if his engine is misbehaving. What would happen if we required that exhausts finished in the front of the car, so that the driver could see them? I bet they would be cleaned up rather quickly. What, furthermore, if we required that exhausts finished on the inside of the car? If I have to breathe in his poisonous exhaust fumes, why does the driver not have to breathe them in?
	Roadside emissions are a particular problem in urban areas of the UK. The index level for PM2.5 in London this morning is 67. Yesterday it peaked at 85. London’s Marylebone Road had the highest concentration of PM2.5 in the whole of Europe in 2012, with a concentration of almost 94 micrograms per cubic metre of air. Furthermore, the UK has failed to meet its recent EU air quality target for NO2—and the annual average for NO2 was exceeded in 38 out of 43 air quality zones. The health benefits in improving air quality are clear, so I ask my noble friend, when will the Government respond to the recommendations presented by the Environmental Audit Committee report of the other place published shortly before Christmas?
	New technologies will provide the key to improving air quality and developing greener transport. When I was a manufacturer of London taxis, I sold thousands of diesel engines. But after that, I spent a fortune on trying to make electric vehicles work, and every penny I made from diesel engine taxis was spent twice over on electric trucks. I started an electric truck business and sold about 400 vehicles worldwide, and I was grateful to UPS, FedEx and Tesco for buying the first ones. This was a great product which worked really well, but to get consumers to change to electric vehicles is a huge leap, and we were just too early.
	When I was trying to sell zero-emission vehicles, I thought of a single product which I believe every British consumer would applaud. Particularly in these election days, I think British people want to find a zero-emission politician.

Lord Berkeley: My Lords, I welcome participating in this debate and listening to what I think is the start of the Liberal Democrat manifesto from the noble Lord, Lord Greaves, and the noble Baroness. I also welcome another engineer to the House of Lords in the shape of the noble Lord, Lord Callanan. I welcome his speech. There are not many of us and he has added quite a high percentage because of that.
	The noble Baroness and my noble friend Lord Whitty made a powerful case for change, which I fully support. I want to outline some of the difficulties that we will have in achieving it, especially when people have the time, energy and resources to fight for or against it. Sometimes, of course, even those who are in favour of a particular green or environmental initiative actually spend more time fighting each other than achieving their objective.
	I will give two examples. First, I will say a little more about air pollution, on which the noble Lord, Lord Borwick, gave us some very interesting data. The noble Earl, Lord Selborne, and the noble Lord, Lord Bradshaw, also mentioned this. We started off with a Question on 6 January which I put down about the premature deaths caused by nitrous oxide and the PM2.5 from diesel engines. We can all disagree on the exact number of people who may have died prematurely nationwide. The figure I cited was 55,000 people nationwide, with an average loss of life expectancy of more than 10 years. Other people have different figures, but I do not think it really matters. We can go on discussing the figures ad nauseam, but I think we all agree that the figure is very high and it could be reduced.
	Again supporting the statement by the noble Lord, Lord Borwick, Dr David Carslaw, who is a highly respected scientist, has said that the pollution in Oxford Street is the highest in the world. That is a pretty challenging statement to make. I suspect he is right. The NO2 annual concentrations and the hourly exceedances in Brixton Road may exceed those in Oxford Street in 2014. It is easy just to talk about London, but I think the problem is just as bad in many other cities.
	The easy solution is to get rid of the polluting diesels, as the noble Lord has said. But how are we going to know where the problem is? The solution, of course, is by the network of measuring stations that, at
	the moment, local authorities are required to run. I have it on good authority that, before the London Olympics, the Mayor of London covered up the stations that were reading a bit high. Otherwise, the Olympics would have been performed allegedly in an atmosphere that was worse than that of Beijing four years previously. Whether that is true, I do not know.
	Of course, it is much easier to deal with the problem by removing the evidence. I think it is extraordinary that Defra wants to remove the requirement for local authorities to keep maintaining such measuring points. It is going to be very easy for a future Government to say, “Well, there is no evidence of air pollution”. The noble Lord may be right that we will be able to measure it on our mobile phones. However, at the moment, having some official statistics is extremely important, because it is easy to say, “Well, there is no evidence, therefore we don’t need to tackle the problem”. Are the Government really allowing 55,000, or whatever the number is, premature deaths to continue because they will not only not ban diesels in the worst polluting areas but now want to remove the source of evidence as to where they should act?
	My second example is railways—no great surprise there—an environmentally friendly type of transport and probably the best one, apart from walking and cycling, if people feel the need to move around. The issue of nimbyism is, I am afraid, as rife as ever. We have seen it in all the debates on High Speed 2. People even complain when the railway is in a tunnel, under- ground, two or three miles from their house; they say it will still affect them.
	I have heard a more recent example in Bath, which I think is more serious. Noble Lords will know that the Great Western railway is being electrified. When you are putting wires above the trains, you need extra height, which means that you either lower the tracks or you raise the bridges. There is a very famous tunnel, which Brunel built, called Box tunnel, where the tracks have to be lowered to get the wires in. The problem is that there are bats in the tunnel. I love bats and have many friends who love bats. They seem to have survived and prospered in this tunnel for 150 years or so, even when 125 miles per hour trains are rushing through every 15 or 30 minutes.
	The only time that Network Rail is allowed to lower the tracks in this tunnel is in July and August, due to the bat breeding season or something—it will do a lot of other work at the same time, which I could explain but will not now. That means that the railway through Bath has to be closed for two months in the summer. Bath, as we all know, is a World Heritage Site and summer is a good time of the year for tourists from around the world to come to Bath. However, because there are no trains, and Network Rail obviously finds it necessary to help move passengers around, it has to use buses. I am told that there will be 200 buses going in and out of Bath for two months in July and August.
	We have to have a specially designed catenary because it is a World Heritage Site. We have to drop the track, which may end up on an old Roman ruin, which will probably close the line for another six months while the archaeologists dig. The question is: what price
	progress? This is one of the reasons why the cost of electrification has doubled around there. It is not Network Rail’s fault, because it has been told to do it this way, but one rather thinks that if the people of Bath and the people who are requiring all these changes do not want electrification, we should give them a steam train instead. We can let the people of Bristol get to London on the other route through Bristol Parkway and have a chuff-chuff between Bristol, Bath and Chippenham. They can pollute their town with smoke instead. Is it really justified for the bats, which clearly have to be protected to the extent that they can have a tunnel dug up only in August, although they survive all the rest of the year round with all this noise going through?
	It is a question of what price we pay for progress, a debate that we will continue to have for a long time. There is an added cost and there are a lot of people who feel very strongly about this, but we have to have a balance. I hope in the future we will get a better balance.

Baroness Janke: My Lords, coming from Bristol, I would not dream of speaking for colleagues in Bath, but we have always had a great aspiration for this improvement and I certainly add my support to it.
	It is a great pleasure to speak in this debate as a former leader of Bristol, which is the 2015 European Green Capital. The Green Capital bid was based on all-party support. Bristol’s success in winning has led to greater developments on the green agenda—which is of course, as my noble friend Lady Bakewell said, a key Liberal Democrat priority, whether nationally or locally. One of the success criteria in the Green Capital award is the need to demonstrate ways that achievements have been made to help other cities and communities reach key European targets in carbon reduction, energy conservation and increasing the use of renewable energy. Bristol has the lowest carbon emissions of any of the core cities and has achieved a reduction of 20% per person over the period from 2005 to 2012.
	Strategic leadership has been important, and the council leadership has been acknowledged for establishing some key strategic projects such as a comprehensive programme of energy efficiency, a successful bid for the cycling city and, of course, the local energy supply company. The energy efficiency project has insulated 30,000 homes. As a result of the cycling city project, we have three times the number of cyclists as the core city average. The city council has taken a strong lead in exploiting its own energy through solar panels and the wind turbines at Avonmouth, enabling the establishment of the energy supply company.
	However, it is important that people from all sections of our communities can contribute to these targets and to achieving a greater quality of environment. We have to change hearts and minds as well as providing strategic leadership. There have been some innovative and energetic projects in the city, some of which I would like to tell your Lordships about. In some of the poorest areas of the city, we have a project called smart metering, which enables people to measure energy usage using the wi-fi hotspots that we have created there and by using recycled computers. This has made
	a valuable contribution to awareness of energy use and to future energy use within those communities, and has motivated much more learning about how people, within their communities, can make real changes. The council also started a green volunteer scheme, which links organisations with would-be volunteers. In conjunction with that, we set up an annual award scheme to recognise volunteering across the city, so that individuals and community groups that use volunteers and companies which support volunteering from their staff can be accredited, acknowledged and thanked.
	Local sustainable food, and educating people about local food, has moved quickly up the agenda in recent years, with the Green Capital year being a catalyst for many local food projects being instigated in Bristol—I hope that many of your Lordships have heard about the food programme that comes from Bristol and some of the very innovative projects that we have there. One example is the Severn Project, which works with socially excluded individuals to reduce anti-social behaviour by using the production of food as a vehicle to provide education, training and employment. The organisation has a temporary lease on a derelict area of land near the station that is earmarked for development. Despite the site being severely contaminated, the project has installed polytunnels and put down membranes to bring in compost to grow salad crops, which are then sold on to local restaurants and businesses in the city.
	Another unique feature is the Bristol pound, which I think is the UK’s first citywide local currency, the first to have electronic accounts managed by a regulated financial institution and the first that can be used to pay some local taxes. It was set up by a community group and supported initially by a small grant from Bristol City Council. It has now grown thanks to EU funding and other sources, and nearly 1,000 traders in the city accept the currency. For people who do not quite understand how this contributes, it is a way of boosting independent producers and creating local sustainability within the local economy.
	There is still a great deal to be done in relation to our international competitors. However, to make real progress it is important to change hearts and minds and to involve all the people and communities, groups and enthusiasts, wherever they are. With strong local and national leaderships, we can harness the energy of individuals and groups and achieve immense benefits in terms of the quality of the environment, as well as reduction of emissions, generation of green energy and conservation of energy—all of which bring huge benefits in terms not only of the quality of life but of the health and well-being of people and communities.

Lord Smith of Finsbury: My Lords, I join in thanking the noble Baroness, Lady Bakewell, and congratulating her on initiating this debate. Her Motion does a crucially important thing, because it helpfully links the challenge and impact of global climate change with the importance of the local environment that we all live, work and play in. It is a hugely important link to make.
	Climate change is of course very much with us. Thirteen of the 14 warmest years on record globally have happened in the 21st century. The sea level rise
	over the last two decades across the world has been 3.2 millimetres per year—nearly twice the average rate for the 20th century. Here in the UK, we have, as the noble Baroness alluded to, experienced extreme weather events over the last couple of years. I lived through the last winter as chairman of the Environment Agency. It was a traumatic period, especially for those people who were tragically affected by the flooding that occurred. That was a result of the biggest surge in the North Sea that we have seen in 60 years. There were violent storms over the course of Christmas and the new year, and the wettest January and February we have ever experienced in 250 years had an extreme impact on people with businesses around the country.
	It is not just flooding. We are seeing more extremes of weather, both floods and droughts. In March 2012, when we were facing the imminent prospect of serious drought, the River South Tyne was running at 28% of its normal flow level for that time of year. Three months later, in June 2012, it was running at 406%. We are increasingly experiencing these extreme weather patterns. Over the last 30 years river temperatures across England have risen, on average, by 0.6 degrees.
	We are seeing an impact on species too. The vendace, which is a very beautiful coldwater fish, has lived in the Lake District for centuries. We have now had to move them to higher lochs in Scotland in order to ensure they have the cold water that they depend on. Damsel-flies are now being found 40 or 50 miles further north than ever before. They are moving with the temperature. All this shows something of the impact that a changing climate is having on habitats, species, the nature of our countryside, the quality of our rivers and on the fate of the environment around us.
	The importance of that natural environment needs to be emphasised again and again. I am delighted that the Government have realised some of this. The natural environment White Paper and the establishment of the Natural Capital Committee are welcome initiatives. The environment is not just something for us to wonder at, to enjoy, to find pleasure and to seek recreation in. It is also part of the natural capital on which we all depend. It is a resource, an essential part of our economic and social life. It is something we cannot do without and that we endanger at our peril.
	Yet do we fully understand the importance of this natural bank of capital when we make decisions about what happens to our landscape, green spaces, trees and rivers? When we think about how we address the growing impact and prospect of climate change? I fear that, too often, we do not. The noble Lord, Lord Framlingham, talked movingly about the importance of trees. I could say exactly the same thing about our rivers. They are, of course, a source of life. They provide us all with water, but they also sustain industry, irrigate crops and permit agriculture in places where it would otherwise be impossible. They are also an ecological resource—a place for insects, fish and water-bank mammals—and we need to look after our rivers in order to sustain it. This includes responding effectively to floods and droughts in order to protect not just our water supplies but this rich diversity of habitat, too. Let no one tell me that European intervention has nothing to offer, when it is precisely things such as the
	habitats directive and the water framework directive that have provided the underpinning for a lot of the environmental protection that we need and value in this country.
	This brings me back to those links between the enormous issue of climate change and our own local environment. Why is it that the environment rates so low among current public political concerns? Surely it is because we tend to speak of it in abstract terms. However, when you ask people about their own, personal, local patch of environment, they become really passionate about it. Their own piece of green space and the river at the bottom of their town are bits of the environment that they really value. We need to ensure that we link the value placed on those with the big, global issues that we also need to address.
	The Royal Society for the Protection of Birds does this rather powerfully and brilliantly. I sometimes remind my former political colleagues that the RSPB has more than twice as many members as all the political parties in Britain put together. They do something that is very radical and progressive. They take people and say, “You are interested in something very small, very fragile—a dipper. If you are interested in a dipper, you need to understand about what happens to its habitat, to the rivers, hedgerows and fields. If you want to understand about what happens to those, you need to understand about the planning and development pressures, about agricultural production and what is happening to it and about the framework of local plans that decide what should happen to landscape and habitat. Then you need to understand the national framework that operates to determine and protect all this, what the European Union is up to and the international agreements that are reached in places such as Kyoto, Lima and, hopefully, Paris”. Before you know where you are, you have taken people from something very tiny—a dipper—to an understanding of the global forces that shape the importance of our environment. It is an understanding of how everything, from top to bottom, is interlinked. That is the realisation we need to capture. This debate has helped us to do precisely that.

Baroness Ludford: My Lords, I, too, congratulate my noble friend Lady Bakewell on introducing this debate. I will follow other noble Lords in concentrating on air pollution, especially from vehicles.
	As another former Member of the European Parliament, it is a pleasure to welcome my noble friend Lord Callanan. We will both have to get used to calling each other that.
	I, too, am grateful for the recent Environmental Audit Committee report in another place. As time is short, I would just urge noble Lords to read it. I broadly agree with it. It is nearly 60 years since the Clean Air Act and more than 40 years since the Control of Pollution Act. I was, briefly, a very junior civil servant and worked on drafting the latter. It is a scandal that, all these decades later, we are not dealing with what has become the number one environmental health challenge. It is estimated to cause 29,000 premature deaths a year in this country and 7 million or 8 million worldwide. It is not just diesel exhaust but air pollution
	as a whole that is classed as carcinogenic by the World Health Organization. London seems to have the highest monitored nitrogen dioxide levels in the world—three times WHO limits, especially on Oxford Street and Marylebone Road.
	Quite rightly, there has been great emphasis on carbon dioxide limits in the tackling of climate change—no one, certainly not a Liberal Democrat, would quarrel with that. However, there has been an overlooking of the problems and challenges of air pollution. I agree with the noble Earl, Lord Selborne, that it needs to go very fast up the policy and political agenda. I applaud the Healthy Air Campaign, which is run by a group of non-governmental organisations, and also Living Streets, which emphasises how tackling air pollution can make life much pleasanter and safer for pedestrians.
	Liberal Democrats have long championed the need to tackle air pollution as well as climate change. Perhaps I may quote from a document which is headed “Localised Air Pollution”. It says that, “There is increasing evidence that many people in the UK become exposed to concentrations of pollution above World Health Organization guidelines as the result of emissions from road vehicles. This includes ground-level ozone, which is a problem in both rural and urban areas, nitrogen dioxide at urban sites, PM10s —the fine particulate emissions from diesel engines”. That was in a Liberal Democrat policy paper of 20 years ago. The working group was chaired by my now noble friend Lord Bradshaw. My noble friend Lord Tyler was also a member of that group. So, we are not Johnny-come-latelys when it comes to tackling air pollution.
	I congratulate the successive holders of the post of Secretary of State for Energy and Climate Change in the current Government. I believe that they have been more active than their counterparts at Defra in dealing with air pollution and that there has been some complacency at Defra on the issue. One of the most urgent requirements is to update the air quality strategy in this country. We need a holistic approach and a clear demarcation of responsibilities and resources as between central government departments and between central and local government. One rather simple thing that could be done is to incorporate pollution warnings into weather forecasts as happens with pollen counts. There seems to be a curious contrast in those things. The planning framework needs to place much more emphasis on air quality matters. Locating schools and new homes away from main roads is one example.
	Although I cannot enumerate all the issues that need attention, one of them, of course, is airport construction. We need explicit air quality objectives for the current Airports Commission appraisal framework. Liberal Democrats believe, of course, that aviation expansion must not further damage health. That is the reason for our negative response to suggestions to build new airports, particularly in the south-east. As others have said—including, I think, the noble Lord, Lord Berkeley—we must not allow the Red Tape Challenge to undermine local air quality monitoring.
	As others have also said—I will not dwell on this—the main problem is diesel engines. Although there were undoubtedly good reasons for encouraging diesel, it is
	way past time for a radical change in policy direction. That will mean giving attention to the fiscal and other frameworks—such as fuel duty, vehicle excise duty and so on—under which people have been encouraged to go for diesel. I do not own a car but sheepishly admit that, as a member of a car club called Zipcar, I find myself involuntarily driving cars with diesel engines. I do not drive frequently but when I do, the engines always seem to be diesel. Can my noble friend say what the Government are doing to remove the loopholes whereby diesel particle filters are removed after being factory fitted? People are apparently managing to remove them through these loopholes, so I would very much welcome a specific answer on that. We need to aim for the adoption of zero-carbon technology in motor vehicles and in London. Liberal Democrats propose having a big switch to 100% electric buses, taxis and vans. We regard the Mayor of London’s ambitions for the ultra-low emission zone as lacking both urgency and stringency. We need to go much further and much faster.
	We work in a European context because air pollution does not recognise national boundaries. The coalition agreement pledged compliance with EU clean air laws but the UK is massively in breach of these laws and is thus subject to legal action. We are 20 to 25 years late in the schedule. My noble friend Lord Callanan and I are not quite on the same page on this matter. He says that air quality rules must not impede economic growth but that is a false choice. I also venture to suggest that the engineering companies of the north-east could make big business out of clean technology.
	My last question to the Minister is therefore to ask whether he will update us on the Government’s efforts to ensure that the EU’s ambitions for clean air will continue and to dissuade the Commission from withdrawing its proposals for new air quality directives. Unfortunately, I believe that there is a lack of consensus in the European Parliament to pass a resolution now to urge the Commission not to withdraw these measures. It was disappointing that the Environment Secretary was not a signatory of a letter from the national Environment Ministers to the Commission President urging against withdrawal. Will my noble friend tell us whether the Government are determined to press forward to meet EU laws?

Lord Grantchester: My Lords, this has been a wide-ranging debate, covering many aspects of our modern environment and touching on the policies of many government departments. I thank the noble Baroness, Lady Bakewell, for introducing the it and declare my interest as a farmer, and my previous experiences of being involved along the food supply chain with various organisations.
	The noble Baroness, Lady Bakewell, was quite right to frame the debate around climate change. In the UK, the most significant impacts of climate change are likely to be further increases in the frequency and severity of extreme weather, heat waves and drought, as well as storms and flooding. How we respond and adapt to this is critical. The sixth annual report to Parliament of the Committee on Climate Change scoped out the progress towards meeting carbon budgets and emission
	reduction targets, and reflected on the progress across the main government departments of energy, local government, transport, business and the environment, as well as in the Treasury and the devolved Administrations. This throws up a clear challenge for joined-up action and co-ordination. The warning is clear: the committee considers that the underlying pace of emissions reduction, allowing for the impacts of the recession through the first carbon budget period and in 2013, is insufficient to meet future carbon targets and budgets.
	Meeting the legislated fourth carbon budget in the 2020s to reduce emissions by a further 31%—that is, by 50% from the 1990 levels—will require further strengthening of policies, which speakers throughout the debate have highlighted. On the energy front, there are the policies for energy efficiency and power decarbonisation; on the transport side, it is those for the electrification of transport; on local government policies, they are for infrastructure and green spaces; and on Treasury policies, they are for financial incentives across other departments’ policies.
	In the Minister’s own Department for Environment, Food and Rural Affairs, it is therefore extremely disappointing that the Government’s failure to get to grips with the increasing threat of climate change is putting more homes at risk from flooding. I am sure that the Minister will be regretting the previous Secretary of State’s removal of “preparing for and responding to flood risk” from the department’s list of priorities and the consequential ideological cutting of the budget. Since 2010, the Government have cut the Environment Agency’s flood defence budget by £138 million, a 21% reduction. It was especially instructive to hear from the noble Lord, Lord Smith, about his experiences at the Environment Agency.
	The next Labour Government will reinstate flood protection as a core departmental responsibility and establish an independent national infrastructure commission to identify the UK’s long-term infrastructure needs, including on flood defences. The next Labour Government will also introduce a new national adaptation plan across government to ensure that all sectors of the economy are adapting to climate change. This will build on the work on the adaptation sub-committee of the Committee on Climate Change, whose 2014 report underlined the importance of infrastructure resilience, the risks to businesses, well-being and public health, and emergency planning—especially in this area of flood risk.
	The Government should introduce without further delay the Flood and Water Management Act’s provisions to require sustainable drainage in new development, as recommended by the Pitt review. They should also now evaluate whether local flood risk management arrangements are in place across the country, in line with this review. The adaptation sub-committee found that some funding provided by Defra to lead local flood authorities is being diverted to other council services. Statutory local flood-risk management strategies have yet to be published in many areas. Will the Minister initiate and publish an assessment on local action plans? Does he also regret the abolition of the Cabinet committee on improving the country’s ability
	to deal with flooding and the national resilience forums? In addition, does he agree that the Government should bring forward the reform of the water abstraction regime to encourage water efficiency and protect the environment?
	The noble Earl, Lord Selborne, raised the issue of air quality, which was further taken up by the noble Lord, Lord Borwick, my noble friend Lord Berkeley and the noble Baroness, Lady Ludford. Air pollution in our towns and cities causes 29,000 people in the UK to die prematurely. Rather than simply devolving the responsibility to local authorities, making them liable to million-pound fines for exceeding EU air pollution limits, what are the Government doing to devolve the power to local authorities willing to take action against this public health crisis?
	The next Labour Government will deliver a national framework for low emission zones to enable local authorities to tackle the problem by encouraging cleaner, greener and less polluting vehicles. Currently there is no such framework, despite the majority of councils calling for one. The next Labour Government will devolve the power, not just the responsibility, to take action against air pollution to local authorities. Can the Minister update the House on discussions with the EU Commission and other Governments to ensure that the EU delivers a widely reformed, tougher clean air package?
	Transport-vehicle emissions are clearly critical in this regard. I certainly enjoyed the maiden contribution from the noble Lord, Lord Callanan, and hearing of his experiences drafting EU emissions standards, which I agree should not be set so that they damage British interests. The theme of further encouragement of good British innovation and development was taken up by the noble Lord, Lord Bradshaw.
	Biodiversity and the importance of trees and wildlife were also key themes throughout the debate. Again, clearly the Minister’s department has struggled to provide the required leadership. The noble Lord, Lord Framlingham, highlighted the role of trees. Can the Minister update the House on the protections that his Government are now taking following the importation last year of diseased stock with ash dieback?
	On wildlife protection, can the Minister update the House on legislation on the control of trade in endangered species? It is now nearly a year since his department conducted consultations. Does the Minister have any timing for when his department will bring forward measures to combat wildlife crime? Does his department have any plan to publish the report of the National Wildlife Crime Unit?
	The noble Lord, Lord Greaves, was keen to understand how to understand how cuts at Defra have undermined key services. He mentioned footpaths and green spaces. With important considerations of environmental concerns across government departments, how is the Minister’s department co-ordinating scarce resources so that the public purse can be leveraged to meet important considerations, as has been debated today?

Lord De Mauley: My Lords, I thank my noble friend Lady Bakewell
	of Hardington Mandeville for raising a range of important matters today. I warmly welcome the chance to discuss the importance of our natural environment, and the need to reduce emissions, improve green transport and protect wildlife and green spaces.
	Most people agree that the environment is important for its own sake. In addition to this intrinsic value, we recognise that the environment provides a range of essential services to society. We all rely on it for our clean air, water, food, energy, opportunities for recreation, and for the contribution that it makes to our well-being. We are deeply committed to improving our natural environment. We have set out that we want ours to be the first generation that leaves the natural environment of England in a better state than when we inherited it.
	We know that our environmental goals are challenging and long term, and that they cannot be achieved easily or overnight. Furthermore, government cannot do this alone. We need individuals, businesses, farmers, land managers, community groups and NGOs to work together. We have put in place an ambitious programme of environmental policies to protect the environment for future generations, including bringing forward the first White Paper on the natural environment in 20 years. This has a strong focus on changing how we view the natural environment and on taking better account in decision-making of the many benefits that nature provides to people. We have already implemented the majority of the White Paper’s commitments, putting in place foundations for the longer term.
	We are making progress in many areas. For example, our rivers and coastal bathing waters are getting cleaner. Background concentrations of key air pollutants, such as nitrogen dioxide and particulate matter, halved in the 20 years up to 2012. We have introduced marine plans for the first time and greatly increased the network of marine- protected areas. We have supported the planting of more than 8 million trees, and woodland cover is at its highest level in 700 years. We have also recently published our pollinator strategy. Looking ahead, we will be investing more than £3 billion from 2014 to 2020 to deliver environmental benefits through the new Rural Development Programme for England. This is in fact a larger share of the overall budget than previously.
	My noble friend Lady Bakewell raised the need to reduce emissions, about which we can all strongly agree. The UK is committed under the Climate Change Act to cut emissions by 80% by 2050 and the Government take this extremely seriously. We want to make sure that the UK makes a cost-effective transition to that target. We were pleased to be able to announce in February last year that the UK had met the first carbon budget for the period 2008 to 2012. Furthermore, the latest published projections show that the UK is on track to meet the next two carbon budgets, up to 2022. The Act has helped drive the UK to reduce emissions by almost a quarter since 1990. The Climate Change Act was the first of its kind. Almost 500 climate laws have now been passed in 66 of the largest emitting countries around the world.
	My noble friend Lady Bakewell also mentioned green transport. It is well recognised that air quality can affect people’s health, which is why we are investing
	heavily in measures to improve it. We have committed £2 billion to increase the uptake of ultra-low emission vehicles, sustainable travel and green transport initiatives. Overall, air quality has improved significantly in recent decades and the UK currently meets the EU limits for almost all pollutants—though of course we recognise that more needs to be done.
	We are also taking action for England’s wildlife through our biodiversity 2020 strategy. For example, since 2010 we have set in hand the creation of nearly 150,000 acres of wildlife habitat, such as field margins, wetlands and woodlands. As part of our strategy, we have established a new, more joined-up approach to conservation—to which my noble friend Lady Miller of Chilthorne Domer referred—through the 12 government-funded nature improvement areas, which are now starting to deliver real improvements on the ground.
	Earlier, I mentioned the essential services that nature provides. One important example, to which I have already briefly referred, is pollinators. We are taking action to support bees and other pollinators through our National Pollinator Strategy, launched in November. The strategy includes actions to improve habitats for pollinators across all land uses in England, enhance our response to pests and diseases, and improve our evidence base, particularly on the current status of pollinators and trends. We have also established a local green-space designation within the planning regime to enable communities to identify green areas of particular importance to them for special protection. My noble friend Lord Greaves referred to that.
	I will now address some of the matters raised by noble Lords during the debate. My noble friend Lady Bakewell spoke of allowable solutions and zero-carbon homes. The Government consider that retrofitting existing properties with energy-efficiency measures could indeed be an allowable solution that housebuilders can support in order to contribute to the zero-carbon homes target that will be introduced from 2016. New homes from 2016 will still have to meet minimum energy performance requirements, which will be more demanding than those currently required by building regulations.
	The noble Baroness spoke about energy efficiency and listed buildings, particularly those with thatched roofs and those unable to take double glazing. Green Deal assessors are trained to assess the energy efficiency needs of all property types and to make recommendations suited to the building, including listed buildings or those with a thatched roof. If a Green Deal plan is put in place, there are specific requirements within the code of practice for Green Deal providers to ensure that the energy-efficient measures are suitable for older or traditional-style buildings.
	My noble friend Lord Selborne mentioned the Aichi targets for biodiversity, which form part of the Convention on Biological Diversity strategic plan agreed in 2010. The UK has reported to the convention on its implementation of this plan. The report set out that we are making progress in most areas of the five strategic goals of the plan with substantial progress in some areas. My noble friend asked about the Natural Capital Committee, which we established to advise us on the sustainable use of natural assets and on our priorities for action to improve and protect nature. It
	is intended to support a transformation in the way we view and value our natural assets. Its third report is due on 27 January. The Government will consider it carefully when it is received before deciding on their response.
	My noble friend spoke about hydrogen in the context of transport. We are technology neutral, and we believe that hydrogen fuel cell vehicles have a potential role to play alongside battery electric vehicles and plug-in vehicles. In October, we launched the hydrogen technology advancement programme which will see investment from government and industry in new and upgraded hydrogen refuelling stations and support the deployment of hydrogen fuel cell electric vehicles in public sector fleets. My noble friend Lord Callanan, whose maiden speech we all enjoyed so much, will be pleased that these will contribute to growth and exports in those areas.
	My noble friend Lady Miller and the noble Lord, Lord Berkeley, spoke about bats. What is needed is for wildlife and humans to be able to exist in harmony. It is about balance. I am unconvinced that the Private Member’s Bill that my noble friend referred to will achieve that. She will be pleased to hear that we have worked closely with the churches. I visited a church in Norfolk where the damage was very extensive indeed. I am pleased that we have been making important progress with equipment using light and sound to move bats to places where they do less damage. I will look at the railway problem that the noble Lord, Lord Berkeley, raised.
	My noble friend Lord Bradshaw was one of several noble Lords who focused on air pollution. He is right that emissions from small diesel engines of the type used to power mobile refrigeration units are not currently regulated. The European Commission recently published a proposal to revise the legislation related to exhaust emissions from engines used to power small diesel engines of this type. That proposal, if adopted, would bring those engines into scope. The revision is currently in the early stages of negotiation in the Council and we are considering the proposal, but the general consensus among member states is favourable towards it. My noble friend’s solution is interesting. It is primarily for industry to take forward, but I would be very interested to see the papers he offered.
	My noble friend and the noble Lord, Lord Grantchester, raised the matter of low emission zones. We are working with local authorities on the feasibility and design of such zones and have provided guidance, such as on what vehicles should be covered and what emission standards they should meet. So far, London, Oxford, Norwich and Brighton have introduced low emission zones. While the main reason for poor air quality is vehicle pollution, sources vary from place to place, so measures need to be tailored to local circumstances. My noble friend raised a point about adequate notice, and I take it.
	My noble friend Lord Framlingham and the noble Lord, Lord Whitty, spoke about trees. As my noble friend kindly acknowledged, I share his passion for trees. I should perhaps declare an interest as I planted 50,000 of them in 2004-05. The forestry and woodlands policy statement sets out our vision for the future of
	England’s forests, based around the core hierarchy of protecting, improving and expanding our national woodland resources. We have made plant health one of Defra’s highest priorities and taken steps to improve biosecurity through, for example, our biosecurity strategy and our tree health action plan as well as our plant health risk register, which now assesses upwards of 700 pests and pathogens. We have also worked hard on enhanced contingency planning. We have supported the planting of more than 8 million trees, 1 million of them in urban areas, and England now has 10% woodland cover—the highest level in 700 years.
	The noble Lord, Lord Greaves, asked about local green space. The important thing is that it is for communities to decide. It would typically be land that is in reasonably close proximity to the community it serves, is local in character and holds a particular significance for that community—for example, because of its beauty, historic significance, recreational value, tranquillity or richness in wildlife. Local green spaces should be designated when a local or neighbourhood plan is prepared, and they are potentially a very powerful tool for communities. Many communities that are preparing neighbourhood plans are seeking to designate green or open areas of significance to them as local green space.
	The noble Lord also spoke of the impact of local authority budgets on rights of way. It is the responsibility of local authorities to complete maps of rights of way. Through the Deregulation Bill, we are introducing a streamlined process for recording them to reduce the burden on local authorities in managing this work.
	My noble friend Lord Borwick spoke of the effect of air pollution on lungs. Evidence linking air pollution with adverse effects on the respiratory and cardiovascular systems continues to accumulate, and the review by the World Health Organization also notes emerging evidence suggesting a possible association with adverse effects on other body systems, including the endocrine system and the nervous system. The World Health Organization has concluded that the evidence suggests that ambient concentrations of nitrogen dioxide have direct effects, particularly on respiratory outcomes.
	My noble friend asked when we will respond to the Economic Affairs Committee report. I anticipate that, in line with the usual timetable, we will be responding in February. I can confirm that of course my department works very closely with the Department for Transport, the Department of Health, the Department for Communities and Local Government, the Department of Energy and Climate Change and Public Health England on air quality.
	The noble Lord, Lord Berkeley, suggested an interpretation of the proposals that could lead to a downgrading of the local air quality monitoring network. The aim of our review is to reduce administrative burdens to free local authority time and resources so that they can focus on taking action to address air quality. It is important that the consultation proposes the removal of the requirement in regulations for local authorities to report on four pollutants that have been well within limits for many years, and monitoring them will remain at national level. The second part contains a number of proposals to do with improvements
	to guidance and includes proposals to streamline the local air quality management reporting system for local authorities.
	My noble friend Lady Janke spoke of her pride at Bristol having been awarded the title of the European Green Capital of the year. It is the first UK city to have this title. I share her pride in that. It recognises that great city’s environmental performance and vision. We are pleased to be supporting Bristol as the European Green Capital with some extra funding to be invested in a range of projects that will help Bristol remain at the centre of green investment and urban sustainability. We wish Bristol every success with the year’s programme of activities.
	My noble friend Lady Ludford raised a number of suggestions for Defra, and I will raise them with my honourable friend Dan Rogerson, the Minister responsible. We are very keen to work in partnership with local authorities and the Commission to avoid any prospect of fines levied from the infraction that she referred to. The main reason for not achieving limit values for nitrogen dioxide is the failure of EU emission standards for diesel engines to deliver the expected emission reductions in real-world driving conditions, and the Commission acknowledges that.
	The increase in the number of diesel cars has, of course, exacerbated the problem. All member states, including the UK, are facing difficulties in addressing air pollution. In 2012, 17 out of 27 member states were non-compliant with the annual mean nitrogen dioxide limit value. We are compliant with EU legislation for nearly all air pollutants, although we still face a significant challenge in meeting the nitrogen dioxide limit and we are working very hard on that.
	The noble Lord, Lord Grantchester, should know that defence against floods is alive and well among Defra’s strategic priorities. That is why we have introduced an unprecedented six-year plan, to which more than £2 billion has been pledged.
	If I have not been able to address noble Lords’ points and questions I will, of course, write to them. We remain deeply committed to improving our natural environment, which is a vital foundation to both our economy and our future well-being. We know that our environmental goals and ambitions are challenging and long-term. We also know that there is much more to be done and that it will require support from others, not just government. We have put an ambitious programme of environmental policies in place to protect the environment for future generations and we will continue to strive, with a wide range of people and organisations, to ensure that it is achieved.

Baroness Bakewell of Hardington Mandeville: My Lords, I thank my noble friend for his very comprehensive reply. There was a great deal of detail in his response to Members’ questions. I also thank all those who have taken part in this very wide-ranging debate. I have been very heartened that we all seem to be on the same page, even if we are covering slightly different subjects. Everyone seems to agree that we need to do something about climate change and work together to
	make that happen. In particular, I congratulate the noble Lord, Lord Callanan, on his maiden speech, and I look forward to his contributions in future.
	I was particularly heartened by the speeches about trees and to hear about the TDAG. I will look further into that organisation. A lot of noble Lords spoke about air pollution: trees are essential in helping us deal with air quality. I will not mention every speaker by name or go through all their speeches because we would be here for ever, but I thank everyone for taking part.
	Motion agreed.

NHS: Accident and Emergency Services
	 — 
	Question for Short Debate

The Lord Bishop of St Albans: To ask Her Majesty’s Government what is their assessment of the pressures facing accident and emergency services.

The Lord Bishop of St Albans: My Lords, I come to this debate not as a doctor with specialist medical knowledge nor with any special insights into the complex processes which hospital managers have to manage. I approach it as someone from an institution, the church, which has been concerned for healing, in its broadest sense, from its very foundation and I live opposite what is left of the great medieval monastery of St Albans, which for centuries was a centre of healing, with its infirmary and herbarium. In my present role, I have regular contact with the hospitals across Hertfordshire, Bedfordshire, Luton and Barnet, which make up the diocese of St Albans.
	I also come as someone who has received the benefits of A&E departments in my own family. Not many years ago, my eldest nephew was diagnosed with a brain tumour and had to have serious surgery on several occasions. Sadly, he has since died from the tumour. About five years ago, he and all the extended family were staying with me for Christmas and, in the early hours of Boxing Day, he had a fit. I remember vividly the intense panic as we were all roused out of sleep to find what was going on; as we waited anxiously for the ambulance, willing it to come because we all felt so helpless; as he was rushed into Watford General Hospital A&E department. What a relief it was, in that terrible time, to feel there were people around who knew what they were doing. I am well aware from talking to doctors and nurses and visiting hospitals that the widespread coverage in the media about A&E departments has not only been frustrating for many of those front-line people but profoundly demoralising. I pay tribute to all who work in such departments and thank them for their tireless service, not least those in Watford General Hospital.
	The House will be aware that pressures on A&E services have been mounting over a number of years. While the NHS always faces pressures in the winter, these have been compounded by our ageing population.
	We now have 350,000 more over-75s than four years ago. This rise has occurred simultaneously with a significant increase in A&E attendances and a greater level of sickness among those who arrive, leading to an increase in emergency admissions of nearly 6% on last year. In my own diocese, the A&E departments are facing these challenges with varying degrees of success. For the week of 5 January, Watford General Hospital fell below the Government’s target of 95% of patients seen in four hours, while Luton and Dunstable University Hospital exceeded this target, in line with its track record as one of the top 10 trusts in the country.
	What is causing this? Attendances are up, but the problems go much deeper. Reports have emerged of people in some places having difficulty getting appointments with their GPs. There have been discussions about changes in social care leaving some elderly and frail people without the necessary support. There are staff shortages and recruitment difficulties in A&E units. Many in your Lordships’ House will be aware of A&E’s three main areas of activity: triage, treatment and referral. Problems tend to arise in bottlenecks at the triage and referral stages. Effective triage is compromised by the presence of patients whose needs do not fit the current services offered in A&E departments. Until quite recently, these individuals were often referred to as “inappropriate attenders”, but current research suggests that it is not the patients who are inappropriate, but the services that emergency departments provide. Estimates vary that between 15% and 40% of patients require services other than those offered by an emergency department and it is the presence of these patients that creates part of the bottleneck at the triage stage.
	At the other end, efficient referral after treatment is compromised by problems in bed allocation in acute medical and surgical wards as well as by accessing appropriate services. In many cases, A&E doctors admit patients for further diagnostic tests or when the additional expertise of medical or surgical staff is required. Around 20% of referrals from A&E to acute wards involve patients whose conditions could be treated appropriately by their GPs or in the community. Up to 40% of patients referred to acute wards are discharged within a few hours of admission. The Department of Health says that the effective management of the flow of patients through the health system is at the heart of reducing unnecessary emergency admissions and managing those patients who are admitted. The problem is how to identify how this can best be done.
	Much of the debate in the other place has, not surprisingly, been highly politicised because we are approaching an election. I hope that, in this debate, this House can stand back and take a more dispassionate view, drawing especially on the huge knowledge and experience of some noble Lords who have intimate, personal working experience in the National Health Service. I hope that we can set this debate in a slightly wider and longer term context. Certainly, it needs to be set against the background that A&E services across Europe are facing similar challenges.
	Until recently, some emphasis has been placed on attempts to demagnetise emergency departments, even though it has long been established that this tactic meets with little success. Both self-referrals and referrals
	from GPs willing to short cut protocols have resulted in increased numbers of patients presenting for treatment. Some 20% of A&E patients decide to attend a day in advance, the majority do not consider going first to their GPs, and 80% fail to make use of advice services such as NHS Direct. While there has been a change in people’s expectations and preparedness to wait for an appointment with their GP, we must not overstate the extent to which A&E services are being clogged up by misuse. The vast majority of A&E users are not inappropriate attenders; that is to say, they should be within the health service.
	Recently, some pilot projects have begun to change the range of services available in A&E departments. For example, some GPs co-locate in emergency departments as primary care physicians while others locate out-of-hours GP services adjacent to A&E departments. Other GP practices have supplemented NHS Direct with their own telephone consultation services, enabling patients to speak with their own doctors. There is growing evidence over the past decade that these approaches relieve pressure on A&E staff and enable efficient triaging at the front door. Similarly, pilot projects that locate acute medical and surgical staff in or approximate to A&E departments at peak times have enabled improved patient flow as additional diagnostic expertise has resulted in inappropriate admissions to acute wards being minimised. Co-location of acute assessment units has also enabled patients to be monitored and assessed without them either remaining in A&E or by being admitted to acute wards. These approaches require strong leadership, close co-operation among health professionals, focus on patient care and strategic implementation. What more can be done to enable every hospital to have its own 24-hour GP practice?
	Ultimately, resolving the current and on-going A&E crisis involves a systematic change to the ways in which health and social care are organised. Access to good social and community care can relieve pressure on GPs, enabling them to play a greater, proactive role in emergency medicine. Allied with a willingness to break down barriers within hospitals between emergency departments and acute wards, strain on A&E staff can be alleviated and patient experience improved. I hope that this debate will play a small part in exploring the complex reasons for the current problems and help us in addressing the challenges facing A&E departments today.

Lord McColl of Dulwich: My Lords, I thank the right reverend Prelate for initiating this important debate. He has set exactly the right tone—let us keep petty party politics out of this and concentrate on the patients. It is important to stress that the staff in A&E departments—nurses, doctors and administrators—are doing a very good job indeed under difficult circumstances. Having worked a lot myself in accident and emergency departments, I know only too well how difficult it is. Patients come in, one is not sure what is going wrong with them, and it takes a little while to sort them out.
	There were some political shenanigans some years ago when there were complaints about people waiting on trolleys far too long in casualty. I produced a paper
	when I worked in No. 10 entitled
	Off Your Trolley
	. The answer was that if you are really ill and they do not know what is wrong with you, stay in the casualty department where all the expertise is—the expert equipment and the doctors and nurses—until an accurate diagnosis has been made. If it worries people that they are on trolleys, they should take the wheels off after 20 minutes and the trolleys will then constitute a bed, so people will not fuss about it.
	Things have improved enormously in this service from the days when I first worked in casualty. I remember once going through the accident and emergency department of a hospital that shall be nameless, where there was a man groaning on a trolley. I went up to him and asked how he was, and he said, “I’m in terrible pain in my shoulder, it’s dislocated, I’ve been here for three hours and I have not seen anyone”. I said, “I could put you in a very comfortable position where you’d be free of pain. Would you like that? I’m not working in the department, but we can get on and do it”. So I put him on his face with his arm hanging over the side of the trolley and the moment when he was in that position he said, “Ah, I’m free of pain”. I said, “Now you’re free of pain, the muscles will relax and the thing may go back on its own, without any anaesthetic—so you go off to sleep and I’ll come back in half an hour and see how things are”. When I came back, he was sound asleep and snoring, so I crept up on him and very gently manipulated the arm. Suddenly, clunk, it went back—and he woke up and said, “Oh, it’s gone back”. I said, “Yes, you can go home now, but perhaps we ought to tell somebody what we’ve been doing”. Things are much better than that now, because we have rapid assessment. Somebody senior goes around the A&E departments, assessing things quickly, so that sort of thing no longer happens.
	There has been an enormous increase in the number of people attending, and we do not know why. As we do not know why, it is quite wrong to start blaming any group of people. It is very demoralising if you are a doctor, nurse or administrator working for the NHS and people start attacking and accusing you of this and that when they really do not know the cause of the increase in the work. What is true is that more resources are being put in and more staff are being recruited, which is good news. But we must stop blaming people and pointing the finger. The blame culture has to go, and we have to be more constructive.
	What is the answer? Preventive medicine is one of the great emphases in the Department of Health, and it certainly helps. We have the worst epidemic that we have had for 95 years in this country—the obesity epidemic—and we need to get people thinned down. They have to eat less and take more exercise. We have to improve people’s health, which will tend to reduce the problem. But we also have to have an alternative way of funding the NHS.

Baroness Gale: My Lords, I, too, thank the right reverend Prelate for bringing this important debate before us today. I may take a slightly different angle from other noble Lords. We are all aware of the problems
	facing accident and emergency services, but the current pressures on them are exacerbated by a consistent failure to properly support people with long-term conditions such as Parkinson’s, both before and after hospital admission.
	In 2012-13, people with Parkinson’s had more than 65,000 unplanned or emergency admissions to hospital, often due to falls, infections or cognitive issues. In England, those over 65 with Parkinson’s are three times more likely to have an unplanned admission to hospital than other people of the same age. In addition to creating serious pressures on already overstretched hospitals, this costs the NHS around £177 million each year. However, with proper support at an early stage, many of these admissions could be avoided.
	Giving people with Parkinson’s the right information and equipment can often help them to manage their condition, rather than relying on accident and emergency services once they reach crisis point. Services such as physiotherapy, dietician support or falls prevention are also a great help in averting health crises, yet access to these services remains inconsistent. Good quality early intervention would significantly reduce the high number of people with Parkinson’s coming into accident and emergency departments in the first place, thereby relieving some of the pressures that hospitals are now facing.
	There is also an urgent need to improve care for people with Parkinson’s once they are admitted to hospital, in order to reduce both avoidable harm and the length of time they are required to stay. Patients with this condition currently spend around 75% longer in hospitals than others of a similar age, equating to more than 128,000 excess bed-days a year. In 2012-13, these excess days cost the NHS more than £20 million. A key reason for this is that many people with Parkinson’s who are admitted to hospital often experience serious disruption to their medication. Parkinson’s medication regimes are often complex, sometimes requiring up to 30 doses at specific points throughout the day. It is vital that people receive their medication on time, because delays can rapidly worsen their symptoms. We have discussed many times in your Lordships’ House the need for these patients to get their medication on time, every time. Anyone with Parkinson’s who does not receive their medication on time is put at risk, and these incidents can create a vicious cycle of escalating care needs for patients with Parkinson’s and overwhelming pressures on hospital staff.
	However, there are a number of straightforward and cost-effective steps that hospitals can take to reduce medication errors and excess bed-days for people with the condition. They include giving patients the option to administer their own medication, as recommended under existing guidelines; taking up Parkinson’s UK’s training opportunities on the importance of medication timing; and making sure that there is always a supply of Parkinson’s drugs in emergency medication cupboards so that they are easily accessible when someone with the condition is admitted.
	I am sure the Minister recognises that there is a clear link between the lack of adequate support for people with long-term conditions like Parkinson’s, and the serious pressures being experienced by accident
	and emergency services. Taking steps to reduce both avoidable admissions and avoidable harm will protect individuals, alleviate the strain on hospitals, and benefit our health service as a whole. I hope that the Minister will take the opportunity to outline how these problems can be addressed as part of the Government’s wider response to the current situation.

Lord Jones of Cheltenham: My Lords, I, too, congratulate the right reverend Prelate on securing this timely and important debate. I should like to focus my remarks on the situation at the Gloucestershire Hospitals NHS Foundation Trust and the critical incidents at A&E at Gloucestershire Royal and Cheltenham General Hospitals. The latest critical incident lasted for more than a week and was lifted only yesterday. Presumably in that time, hundreds of routine operations and admissions were cancelled and have stacked up. This was the second such critical incident at GHT in a month and went on longer than those at other trusts in the country. We need to understand why.
	It is complicated and not simply to do with money. We know that the coalition Government have increased NHS spending overall from £95 billion in 2010 to £115 billion this year, giving GHT £3.6 million for winter pressure this year; so what are the problems? Are too many 111 calls going into A&E? Anecdotal evidence from local doctors says that they are, and certainly the non-medical call-handlers have a naturally risk-averse system that will direct people to a doctor when in doubt. The Prime Minister, in response to a Question from my honourable friend Martin Horwood, said that only 7% of 111 calls ended in A&E. I believe that that was a statistic from October; it would be helpful if the Minister could tell us whether that is increasing and what it has been in the last month or two.
	GHT has implemented what is called the UTOPIA system of routing all unplanned admissions through A&E. Has this made things worse? The theory is that people see a doctor sooner than in direct admission, when they have to wait for the next ward round, but in practice you need enough capacity in the emergency department to handle cases, which GHT pretty obviously does not have. I wonder whether the June 2013 decision to remove doctor cover from Cheltenham A&E at night and route blue-light admissions to Gloucestershire made matters worse. I understand that these decisions were made not due to a lack of money, but simply to the failure to recruit sufficient staff. Is there something wrong with the salary structure within the NHS that particularly affects Gloucestershire? At night, Cheltenham General Hospital is now really a minor injuries unit, although I understand that it still gets help from GPs in the out-of-hours service based at CGH .
	I have spent more time than I care to remember as a patient in Cheltenham A&E. In January 2000, I was there following a sword attack in my constituency office which left my assistant dead and my hands in need of repair with 57 stitches. Then, in 2002, 2003 and 2006 I had three events of flash pulmonary oedema, all at night. This is a deeply unpleasant experience in which the heart goes into a ridiculous non-rhythm and stops pumping and one’s lungs quickly fill up with fluid.
	Fortunately, I was at home when these events occurred; I am grateful for the prompt response of the ambulance paramedics who rushed me to Cheltenham A&E. On two of these occasions my wife was called out of the family room and told to prepare herself for the worst; but thanks to the skill of the truly wonderful doctors and nurses—and, no doubt, a lot of praying in the family room—I survived. I do not know what the doctors did: I was out at the time, but I understand that a super-dose of frusemide was involved. If the recent downgrade of Cheltenham A&E had been in operation then, it would have taken an extra 15 minutes to get me to Gloucestershire Royal. I would probably not have survived and would not be here now addressing your Lordships’ House. Therefore, will the Minister ask the regulators and the Care Quality Commission to look into the difficulties in Gloucestershire to give answers as to why we have experienced these critical incident periods? Will he please ask the Gloucestershire Hospitals Trust to reinstate round-the-clock A&E services at Cheltenham General Hospital and ensure that it has the capability to recruit sufficient doctors, nurses and technicians?

The Lord Bishop of Ely: My Lords, I am very grateful to the noble Lord, Lord McColl, for reminding me how pleased I was to be off my trolley in February 2013, when I was admitted as an emergency patient to Addenbrooke’s Hospital in Cambridge. Were it not for the skill and dedication of the surgeons and nurses—and the grace of God—I would not be here now. Like the right reverend Prelate the Bishop of St Albans, I pay tribute to the dedication of staff in our hospitals, not least Addenbrooke’s, from which no one needing emergency treatment is turned away.
	I support the thrust of what the right reverend Prelate has already said. The immediate problem for Addenbrooke’s recently, in its critical incident over accident and emergency, was the high intake of unusually frail elderly patients in December. They took up more than 300 of the 700 adult beds available. The number of elderly admissions is bound to double—so the chief executive tells me—in the next 20 years. The only immediate resolution was provided by a release of funding and access to beds in social care by the county council.
	I am pleased to commend the even closer co-operation of trusts and social care providers to ease the pressure on A&E and to provide even more joined-up care for the frail and elderly, both in their homes and in nursing environments. The new frailty assessment unit at Addenbrooke’s seems to me a way ahead in offering an overhaul of how hospitals care for the physically and mentally frail patients, and how to keep patients in hospital for the shortest possible time by having such units next to A&E with a resident multidisciplinary team.
	I am also very concerned about the CQC’s report on Hinchingbrooke Hospital in Huntingdon. Without wanting to support poor performance, Hinchingbrooke’s best asset is its dedicated staff. The chaplaincy was one department that was praised in the report. I shall visit staff at the weekend with the chaplain. I mention the Hinchingbrooke situation because a longer-term response
	to this debate needs to be an urgent approach to even closer synchronicity between regional hubs and district hospitals. This will be one such opportunity.
	Very importantly, alongside having GP services available in hospitals, we need to rethink how we recruit younger GPs to market towns and semi-rural settings, such as most of my diocese. In Ely itself, an older profile of GP practice is desperately seeking younger colleagues to take on the profoundly important and complex care needs of the very elderly. The experience of Ely is that recruits are not easy to find. When they are found, they do not often stay, because they are not prepared for the multiple and heavy demands placed on GPs providing clinical, social and pastoral care for elderly patients who are desperate to stay in their own homes, which is much to be commended. We need to support our GPs, as I know Simon Stevens plans to do in his proposed strategy for the future of the NHS. However, this needs to be rooted on the ground in how younger people are formed and prepared for the reality of GP ministry among the elderly in our communities.
	In December, the chief executive of Addenbrooke’s, the clinical commissioning groups and the county council presented improvement plans to Simon Stevens and the chief executive of Monitor. Here was an opportunity to pool together the most effective joint services and investment in a lively, real and continuous approach, beyond any change of Government, to how we unite our health services properly to get beyond immediate crises to a carefully and thoughtful response, particularly for the most elderly members of our communities.

Viscount Simon: My Lords, in opening the debate the right reverend Prelate mentioned people having to wait in ambulances outside A&E departments, in addition to which some patients have to wait at home for ambulances to arrive because ambulances are not available. I wonder how many patients’ conditions, when they arrive seriously ill at hospital, have worsened due to the delay.
	Until recently St John Ambulance could provide a rapid response to patients where and when required, thus keeping conventional ambulances free for other work. It could also provide immediate life-saving intervention in more serious incidents where ambulances were delayed in reaching the patient and when it was nearer. It was able to use blue lights and sirens. It could also use motorcycle units when required, in addition to which motorcycles were used to transport emergency equipment, medicines or other parts very urgently.
	However, following a judgment handed down in the Court of Appeal last March, all response services not involving a conventional ambulance have ceased. The judgment has also applied to many other operating response cars, support vehicles, emergency equipment tenders and the like. Consequently, they can no longer exceed speed limits, go through red lights or do anything else that they used to do under an exemption. A special order under Section 44 of the Road Traffic Act 1988 refers to the use of sirens and lights. It runs from 6 June 2014 until 5 June 2016 and permits vehicles constructed for medical response emergencies that are
	not emergency vehicles to operate within the meaning of the various vehicle lighting and construction regulations. A list has been provided of the ambulance services covered that are associated with NHS trusts.
	As St John Ambulance vehicles are appropriately constructed, I wonder why they have not been included in the list. Is there any possibility of this being amended? It also has very robust driver training standards and compliance. St John Ambulance used to be very useful and very helpful to the accident and emergency services and it still could be if the exemptions that it and other like-minded organisations used to have for vehicles used “for ambulance purposes” were restored.

Lord Greaves: My Lords, I will follow up the remarks that have just been made by the noble Viscount, Lord Simon, on ambulance response times.
	Pendle Borough Council in Lancashire—I declare an interest and remind the House that I am a member of it—has made full use of its new statutory scrutiny powers concerning the health service as laid down in the Health and Social Care Act. A meeting of its health scrutiny panel this week received evidence from councillors and members of the public. For Pendle as a whole, in the three months at the end of last year the number of ambulances arriving within eight minutes was only just over half, at 55.7%. However, in the West Craven area of Pendle—the towns of Barnoldswick and Earby and surrounding villages on what might be called the Lancashire-Yorkshire border country—it was 10.7%, which is clearly not satisfactory.
	Evidence was also received from members of the public on 999 calls that on at least two occasions, on 17 November and 14 December, 999 calls were put through to the ambulance service, but then went on to an answering machine. Clearly that is totally unsatisfactory. I wonder whether the Minister will have a quiet word and find out whether something is seriously wrong in this part of the North West Ambulance Service.
	The rest of what I want to say comes from a hands-on account by a worker at a Greater Manchester hospital who works nights in A&E, which I have very kindly been supplied by UNISON North West. I would like to read out the account that this worker has provided, which shows the pressure that workers such as this are under. The account says:
	“We work as a team—there are doctors, nurses, mental health specialists, radiologists. It’s challenging and rewarding work. Staff work 12 hour shifts and rarely get to take their scheduled breaks. I just have to grab something to eat and keep going.
	We never know what we’re going to encounter … but some things are predictable … a lot of alcohol-related cases up until about 3am. From 5am we begin to get broken hip or fractured neck cases where elderly people have had a fall. These are often people in care homes who are having ‘unwitnessed falls’ when they get up. I think that if there were enough staff in care homes some of these accidents would never happen.
	Sometimes people come in with minor ailments like colds because they can’t get a GP appointment … But our main problem is that we don’t have enough capacity for people who really need to be admitted.
	We see most patients within 4 hours. If they need to be admitted they should then go to the MAU (Medical Assessment Unit) for the first 24 hours, but sometimes there isn’t space … We have some bays on A&E where people can wait on trolley beds,
	but if we have too many then patients can have to wait for 2 or 3 hours on corridors. Ambulance paramedics help to provide the care that patients need while they wait, but it is a frustration to us that they are not being treated in the right environment. Detaining the paramedics also has a knock-on effect for the time it takes to respond to new emergency calls.
	When MAU is full, the registrar will come to A&E and discharge people when they can. This can be a problem and we can sometimes see the same people in A&E the next night and even the night after that.
	If they need to be admitted and there is no room in MAU, patients might be moved out of MAU after less than 24 hours. Other patients who are sleeping on wards can be moved during the night to make space for them to be accommodated. It can be that people end up on a ward that is not best placed to meet their needs.
	We are struggling to provide the level of care that we want to because we don’t have enough capacity. We want to provide the best but the service is always stretched … We feel that we have to work flat out all the time just to keep things going … I sometimes can see that staff are so stressed that they should really be off work, but they won’t take time off as they know that will make things even worse for their colleagues”.
	In a sense, that shows the strength of what is traditionally known as the public service ethos but really it indicates that it is not just when the four hour target is being breached that these kinds of stressful situations and pressures exist, but week-in, week-out through the year, as many of us know from the experience of the people we speak to.

Lord Hunt of Kings Heath: My Lords, this has been an excellent debate. I congratulate the right reverend Prelate for his very penetrating analysis of the challenges facing the NHS at the moment.
	Like other noble Lords, I pay tribute to staff in the emergency services, indeed in the whole of the health and social care system, for the way that they are responding to the enormous pressure. The noble Lord, Lord Greaves, really put his finger on it when he talked about some of the pressures. We know that junior hospital doctors are at the moment not being attracted into emergency departments. Can the noble Earl tell me whether the Government have a strategy for finding ways in which we can both encourage new doctors into emergency departments and also relieve some of the pressure on them so that they do not burn out and find it overwhelming when they face situations as they do today? Will he also respond to my noble friend Lord Simon on the contribution of St John Ambulance and other services like it?
	On the actual pressures, my noble friend Lady Gale spoke very eloquently about the pressures in relation to people with Parkinson’s. The right reverend Prelate the Bishop of Ely talked about the doubling of admissions over 20 years. Can the noble Earl say what the Government expect in relation to flows of patients through hospitals through A&E? He will know that the five year plans of NHS trusts and foundation trusts are all predicated on reducing capacity on the basis that something will happen elsewhere so that patients no longer need to go to hospital. There is very little sign that that is going to happen, and I would like to hear what the noble Earl has to say about that.
	I understand the point about politics. I gently point out to the House that this yearly increase is nothing new. In the previous Government we managed to cope
	with it and keep within our targets. There is no doubt that something has happened. I have no doubt that the restructuring has had an impact. The one thing that is missing above all else at the moment is someone being in charge locally. There is no one single person in a health and care system you can go to and say, “You are in charge. You are responsible”. We desperately need to get that local leadership back.
	On the 111 issue, which the noble Lord, Lord Jones, raised, are the Government going to undertake a review of it? Has the noble Earl seen the evidence given yesterday by Cliff Mann, the president of the College of Emergency Medicine, when he said that the “absurd” 111 helpline is to blame for overloading A&E with patients?
	I also pull up the point made by the noble Lord, Lord Greaves, about the ambulance service. Is the Minister as alarmed as I am by reports today of ambulance staff from the East of England Ambulance Service leaving the dead body of a man on the floor so they could finish their shift on time and indeed the report yesterday of staff there on their own volition apparently not following procedures in relation to the maximum call-out times? What is going on in the East of England Ambulance Service? We need an external review of it. On ambulance services I also ask the Minister about the policy of some services very insensitively called “drop and run” where patients are left at the door of A&E without a proper handing over to A&E staff after a certain time limit of 30 to 45 minutes.
	On the weekly A&E data, one trust last week hit only 53.7% against the 95% target. What impact does the noble Earl think that will have on mortality rates? Is monitoring going on to see what impact that is having on safety and quality?
	Finally, does the noble Earl agree that there are all sorts of issues such as 111, primary care and people’s predilection to come through the door more often because A&E is a place where they are going to get high-quality care from a lot of staff which is not available out of hours elsewhere? However, when it comes down to it one single issue is clearly responsible for most of our problems—the swingeing cuts made by the Government to local authorities and the impact on social care. The real issue is that patients cannot be discharged into the community because the community facilities have gone. What is the noble Earl going to do about that?

Earl Howe: My Lords, I very much welcome the opportunity to debate this important issue and I pay tribute to the right reverend Prelate the Bishop of St Albans for introducing it so admirably. The NHS is facing unprecedented demand with record numbers of people attending A&E and the ambulance services providing record numbers of emergency journeys. Despite this, the NHS is still providing high-quality care, and alongside the right reverend Prelate the Bishop of St Albans and other noble Lords, I place on the record my thanks to all NHS staff for their hard work in responding to this challenging time.
	Winter is always challenging and this year it comes on top of a general increase in A&E attendances. In 2013-14 these were up one-third on 2003-04. So far this year, A&E attendances have been higher than in any year since 2010 with, on average, almost 3,500 more people a day attending. This has led to an increase in emergency admissions of nearly 6% on last year. The noble Lord, Lord Hunt, said that this was nothing new. I have to tell him that it is. It is about the double the trend of increase that we have seen in recent years.
	There is no single cause of the increase in A&E attendances. Healthcare is a system and problems that arise in one part of the system will impact elsewhere. Commissioners and providers need to look at what is happening not just in hospitals but more widely, and address the issues that are most salient in the particular area. That is what they have done in drawing up local plans to spend the £700 million of additional support mentioned by my noble friend Lord McColl that the Government have made available to the NHS so it can ensure urgent and emergency care services are sustainable year round and ready for the pressures of winter. In addition to providing more staff and beds, the money has funded local initiatives including: local information campaigns so people are better informed on where and how to access the services they need; seven-day pharmacy services; enhanced NHS 111 and GP out-of-hours services; and schemes to help people recover in the comfort of their own home after surgery. Some £50 million of the winter money was specifically to support ambulance trusts.
	I have set out what the Government have done in response to the immediate winter pressures. However, we recognise fully that we require system-level change to ensure that services can be delivered on a long-term sustainable basis. I will now set out our longer-term plans to achieve this goal. The right reverend Prelate the Bishop of St Albans called for a systematic review and that is already under way. NHS England’s urgent and emergency care review should improve access to, and the availability of, services outside hospitals. This will involve providing consistent and same-day access to primary and community services.
	The vision for the review is simple. For people with urgent but non-life-threatening needs, the NHS must provide highly responsive, effective and personalised services outside hospital and deliver care in or as close to people’s homes as possible, minimising disruption and inconvenience for patients and their families. For people with more serious or life-threatening emergency needs, the NHS should ensure that they are treated in centres with the very best expertise and facilities in order to maximise their chances of survival and a good recovery. If the NHS gets the first part right, it will relieve pressure on hospital-based emergency services, so that the focus can be on delivering excellent care.
	NHS 111 plays an important role in ensuring that people get access to the right care when they need it. Only around 8% of calls handled by NHS 111 result in advice to attend A&E. In November the figure was in fact 6%. Moreover, 30% of callers say that they would have attended A&E if NHS 111 had not been available. That indicates that NHS 111 is instrumental in diverting people from A&E rather than adding to those attending. It is a myth that NHS 111 makes matters worse.
	Implementation of the urgent and emergency care review will include enhancing NHS 111 so that it becomes the smart call to make, offering a 24-hour, personalised priority contact service. The service will have access to people’s medical history and allow them to speak directly to a nurse, doctor or other healthcare professional if that is the help and advice that they need. NHS 111 will also be able to directly book a telephone call-back service.
	Another key aspect of improving services outside hospitals is providing seven-day access as a matter of course. Currently, not all services are delivered at weekends, and sometimes staff cannot get the advice and decisions that they need from more senior colleagues on Saturdays or Sundays. Delivering the vision of seven-day services could improve the clinical outcome for patients. NHS England is therefore working with NHS employers and staff to develop plans on how seven-day services can be delivered. This should improve outcomes and experiences for patients as well.
	I should like to move on to the better care fund. For the first time, this Government will join up health and social care services through the £5.3 billion better care fund. I can say to the noble Baroness, Lady Gale, in particular, and to the right reverend Prelate the Bishop of Ely that the vast majority of this money is being spent on social care and out-of-hospital community health services. These aim to keep people—especially the frail elderly—out of hospital and, if they have to be admitted to hospital, support them to leave safely as soon as they are well enough to do so.
	Underlying the new approach are improvements in seven-day working across health and social care to help quicker, more appropriate discharge from hospital. One of the metrics for the fund is the number of people supported to remain at home at least three months after discharge from hospital. Plans project that over two years, the number of older people supported to remain at home at least three months after discharge from hospital will increase by 33.7%. That will be good for those patients but it will also save a great deal of money. Schemes in plans typically focus on things such as increasing capacity in reablement or intermediate care services, or multidisciplinary emergency response teams, which focus on avoiding unnecessary admissions to hospital.
	I now turn to our plans for access to primary care. We are offering 7.5 million more people extra evening and weekend appointments, as well as e-mail and Skype consultations, through the Prime Minister’s Challenge Fund, and by 2020 we will offer seven-day GP services to everyone in England. We have announced a £1 billion primary and community care infrastructure fund, which will improve access for millions more people through introducing new models of care and improving estates and infrastructure—including, I am sure, GPs’ surgeries. There are now more than 1,000 more GPs working and training in the NHS compared with the position in September 2010, and there are 40 million more appointments every year than there were in 2008-09.
	I turn to some of the questions that were asked during the debate and, as usual, I shall write to noble Lords whose questions I cannot answer today. The noble Lord, Lord Hunt, made me prick up my ears when he
	said that the problem is that no one is actually in charge of the system. I contend that the system is now more co-ordinated than it has ever been with the system resilience groups that we see in every single area of the health service. These groups comprise commissioners, acute providers, social care and all the players in the system so that they can genuinely co-ordinate their actions and assess the risks and priorities that they need to address.
	The right reverend Prelate the Bishop of St Albans said that people are turning up at A&E when they could go elsewhere, and he is absolutely right about that. The urgent and emergency care review that I referred to noted that it had been estimated that about one-quarter of A&E attendees could have been treated elsewhere. A number of local areas are taking action to make people aware of the range of different urgent and emergency care services that are available and the circumstances in which they should be used, as well as the alternatives, such as pharmacies, that are open to people.
	The right reverend Prelate also asked about staffing, especially doctors—a point also raised by the noble Lord, Lord Hunt. Compared with last year, more than 260 more new doctors will be available in A&E. That is good news. It includes British trainees but also senior staff from other countries, including India, the UAE, Egypt and Malaysia.
	A number of noble Lords, including the right reverend Prelate the Bishop of St Albans, called for more collocation of services. I fully agree with the wisdom of that suggestion. As part of the urgent and emergency care review, NHS England is supporting the collocation of community-based urgent care services in co-ordinated urgent care centres. He may like to know that 112 out of 143 NHS hospitals already have GPs working in, or collocated with, A&E departments.
	My time is nearly up but I want to touch briefly on ambulances. The department is working closely with NHS England, Monitor and the NHS Trust Development Authority to improve performance, and the Government have provided an extra £50 million of funding to ambulance services. However, these services are facing unprecedented levels of demand, with an additional 2,000 emergency journeys a day. Despite that, they are still providing high-quality care. We have introduced the ability to fine providers where handover delays at hospitals are unacceptable. Since then, those delays have gone down markedly.
	I will respond to my noble friend Lord Greaves about the North West Ambulance Service, and I will also respond on the incident of the dead body, which the noble Lord, Lord Hunt, mentioned in relation to the East of England Ambulance Service.
	My time is up but I hope that noble Lords have been able to glean from what I have said that there is a great deal going on. We are gripping the issue. There is no one cause of the increasing pressure on A&E, but we have comprehensive plans, which I have just covered in some detail, to relieve the pressure that we are currently seeing on our A&E services.

Mental Health
	 — 
	Motion to Take Note

Moved by Baroness Tyler of Enfield
	That this House takes note of mental health care provision.

Baroness Tyler of Enfield: My Lords, I am delighted to have secured this debate, and with it such an array of knowledgeable and, I know, passionate speakers. I am particularly looking forward to hearing the maiden speech of my noble friend Lord Suri. For too long, the subject of mental health has been ignored, marginalised or left to the realm of social experiment or institutional stigma. Why does this matter? Just as we all have physical health, we all have mental health. Mental health problems affect one in four people in any given year, and the numbers continue to rise. In 2013, referrals to community mental health teams were up by 13%, and up by 16% for crisis services. As a consequence, services are often unable to cope, and people are not getting the support they need.
	While 75% of people with a physical health condition get treatment, just 65% of people with psychotic disorders, and a mere 25% of those with depression and anxiety, successfully access treatment. John Lucas, a campaigner for the mental health charity Mind, has been diagnosed with both mental and physical health conditions, and speaks compellingly about the discrepancy between the care people receive for mental and physical health problems. He asks:
	“Why does the NHS pull out all stops to stop me dying of physical health problems but does not care if I die of mental health problems?”.
	Importantly, mental health problems are estimated to cost the country £105 billion a year through lost working days, benefits, lost tax receipts and the cost of treatment. So there is also a very strong economic case for investing in well-being, resilience and mental health. It is therefore highly appropriate that this debate takes place at a time when, although a lot of progress has been made, there is still much more to be done. We need to ensure that mental health services are equipped to respond to people with all sorts of mental health needs, ranging from preventive work and early intervention through to crisis care. We need to make sure that people who need mental health services, like those who use physical health services, can access care quickly, and have choices about what kind of care they receive.
	This Parliament has seen real progress in mental health at national policy level. We have made real strides in awareness and public attitudes towards mental health. I pay tribute to my right honourable friends Paul Burstow and Norman Lamb for all that they have done in this area. Specifically, the cross-government strategy No Health Without Mental Health marked a breakthrough moment for mental health, and led the way for the commitment to parity of esteem between physical and mental health which is now enshrined in legislation and in the Government’s mandate to the NHS.
	What has happened as a result? Last year, building on the £400 million investment in talking therapies, the introduction of the first ever access and waiting time standards for talking therapies and early intervention
	in psychosis, backed up by additional cash, was a welcome and long overdue step towards achieving parity of access to treatment for people with mental health problems. The mental health crisis care concordat should ensure that no one is left without support in a mental health crisis.
	All localities have made declarations about working together across agencies to improve crisis care, and progress is already happening on the ground. For example, in Birmingham there has been a marked reduction in the use of police custody as a place of safety. I am sure we can all agree that a police cell can never be an appropriate environment for someone in a mental health crisis.
	Of course, good mental health care is not just about treatment, but about empowering people to lead better lives. Recognising this, we now have more peer support workers in mental health trusts, and some 30 recovery colleges in place, to help people with mental health problems develop and achieve their own goals for recovery.
	We have seen a real sea-change in the way people think about mental health. The MPs who participated in that famous debate in the House of Commons, and spoke so openly and movingly of their own mental health experiences, deserve much praise. Noble Lords in this House have also been open about their experiences. The courage of those in such positions in being open about their own mental health problems has undoubtedly raised the profile of mental health in Parliament—and, I hope, made it easier for others to speak out. Meanwhile, the Time to Change programme, England’s biggest anti-stigma programme, run jointly by the charities Mind and Rethink Mental Illness, is making a real impact both on public understanding and, perhaps more importantly, on people’s experiences of discrimination.
	However, I am a realist, and despite this commendable progress, there is still a long way to go to achieve genuine parity for mental health in the NHS, and an equal chance in life for people with mental health problems. After generations of missed opportunities, I guess this is inevitable. So what are the remaining barriers that need addressing? To put it bluntly, funding for mental health services has faced disproportionate cuts compared with other services. Mental health services have always been known as a Cinderella service because of their chronic underfunding, and mental health receives only 13% of NHS health expenditure, despite making up 23% of what is called the burden of disease. Austerity has hit mental health services particularly hard. Mental health has seen real-terms cuts three years in a row. At the same time, demand is rising. By 2030 there will be approximately 2 million more adults with mental health problems in the UK than there are today.
	Early intervention services are often the first target for cuts, but surely this is a false economy, because people’s problems then get worse, and they need more intensive and costly support. With their new public health responsibilities, local authorities have a real opportunity to prevent mental health problems developing in their communities. It is encouraging that some 35 authorities now have a mental health champion. However, research suggests that on average, councils are spending only 1.5% of their ring-fenced public health budget on mental health.
	Even when people receive care, it is not always helpful. When we are unwell we are often told to see our GP in the first instance, and 90% of people with mental health problems are treated in primary care. But GPs themselves admit they do not always have the training they need to support people with mental health problems. I think all primary care services urgently need GPs and practice nurses with the confidence and expertise to improve people’s experience of primary care.
	Evidence shows that a choice of care improves treatment outcomes, but people often do not receive the type of care they want. Talking therapy is the preferred choice of a majority of people with mental health problems, but only one in seven receive it. That is why I would like to see the right for patients to choose the type of treatment they receive enshrined in the NHS constitution—and for those who would rather have talking therapies than medication, there should be a choice of evidence-based therapies available, backed up by high-quality information.
	I suspect that we can all agree that children and young people’s mental health services are a matter of real concern. Some 10% of children aged five to 15 have a mental health problem, yet funding for CAMHS has fallen by over 6% in real terms since 2010, and the commissioning of these services is far too fragmented, resulting in too many children and young people falling through the cracks. Too often they are taken hundreds of miles away from their home for treatment, or are admitted to adult wards. The Government are committed to fund more children’s beds, which is welcome, and have invested £150 million to improve support for eating disorders. We eagerly await the report of the Children and Young People’s Mental Health and Wellbeing Taskforce—a very long title. Can the Minister say when that is likely to be published?
	Of course, children’s mental health begins at birth. It is critical to children’s mental health and resilience that they develop a secure relationship with their primary care giver—but are we doing enough to support new mothers who develop mental health problems during their pregnancy? More than one in 10 women will experience mental health difficulties during and after pregnancy, which often go unrecognised and untreated. According to the National Childbirth Trust, only 3% of CCGs report having a perinatal mental health strategy. I suggest that we could improve mothers’ access to mental health support by committing to including measurable objectives in the NHS mandate.
	What else could and should be done? Schools have a golden opportunity to protect and promote children’s mental health and emotional well-being, at the same time as helping them achieve good educational outcomes. I would like the next Government to commit to raising awareness of mental health and well-being among young people by ensuring that mental health and emotional well-being form part of an enhanced and mandatory part of the curriculum for all schools, irrespective of their status. Yes, PSHE will be central to this, but such an approach needs to be embedded in the mainstream of the curriculum and the whole ethos of the school. As counselling can be an effective early intervention for young people experiencing mental health problems, and improve students’ attendance, attainment and behaviour,
	I would like to see all children in England having access to counselling, as children in Wales and Northern Ireland do.
	People with mental health problems also face difficulties finding and keeping employment—2.3 million people with a mental health condition are out of work. Almost half of those receiving employment and support allowance are claiming primarily because of mental health problems, yet research shows that the vast majority want to work. It is clear that back-to-work schemes have little understanding of people with mental health problems and often assume that they lack motivation and willingness to work. What we need is personalised and specialist support to help them back into work, designed around the specific needs of people with mental health problems.
	Finally, parity of esteem needs to be genuinely inclusive and work for all, including those who find themselves excluded or marginalised from society—those who are isolated or that third of people living with a long-term physical condition who also have a mental health problem. Certain black and minority ethnic groups and people with multiple and complex needs are often overlooked. People with a dual diagnosis—for example, those who have been diagnosed with a drug and alcohol problem as well as with another mental illness—are often denied access to mental health care on the ground that their substance abuse makes treatment impossible. When they are in crisis, they are more likely to be taken to a police cell than a health setting. It should not have to be that way.
	Charities working together as part of the Make Every Adult Matter coalition, which I chair, have shown that by effective joint working, better care can be achieved for people with complex needs. I am pleased that the Department of Health is currently reviewing the 2002 guidance on dual diagnosis and hope that the continued rollout of liaison and diversion schemes will also start to address the issue of drug and alcohol abuse.
	The next Parliament should set out an ambitious agenda for mental health. What should it be? Here is my starter for 10: mental health is not just a health issue. Therefore, we need a truly cross-governmental mental health and well-being strategy embracing issues such as employment, welfare, policing and criminal justice, housing, education and planning, as well as seeing Public Health England lead with the establishment of a national well-being programme championing preventive action. To lead this charge I would like to see a dedicated Minister for mental health with a cross-government remit and, indeed, the Secretary of State for Health reporting annually to Parliament on progress towards achieving parity of esteem between mental and physical health.
	Next, we should rewrite the current system which discriminates against mental health and leads to institutional bias, including: making the NHS constitution fairer; introducing a wider range of access and waiting-time standards, along with entitlement to NICE-approved treatments for mental health problems; revising payment systems to put mental and physical health on an equal footing; and better aligned NHS public health and social care outcomes frameworks which put much greater emphasis on mental health. Finally, and perhaps most importantly, we should rebalance the NHS budget
	to ensure that mental health services for children and adults receive their fair share of funding and that metal health services see real-terms increases in investment in each year of the next Parliament.
	To conclude, much progress has been made in mental health over this Parliament. The next Government—of whatever complexion or, indeed, combination—have a real opportunity to build on this momentum and transform the way in which we approach mental health in this country. It will take strong and courageous leadership both politically and from within the NHS, but the prize in terms of the nation’s well-being could be immense. I very much look forward to hearing what other noble Lords have to say on the matter. I beg to move.

Lord Goodlad: My Lords, I congratulate my noble friend Lady Tyler on securing this debate and on her and very wise words.
	I speak from the perspective of one whose home for the first 14 years of my life was a mental illness hospital: the Lawn in Lincoln—founded by the Willis family in 1819, following the successful treatment of King George III—of which my late father was for many years the medical superintendent. People have said to me, “What an unusual upbringing that must have been”—to which my only reply is, in the spirit of Elvis Presley, “She’s a distant cousin but she ain’t too distant with me”. An unusual upbringing it may have been, but it was not unusual for me. As I look back on those years, the memories of friendships with patients and staff remain with me as if it was yesterday. I see that part of my life through rose-coloured spectacles. My father wanted me to follow in his footsteps, as for some years did I. When that was not to be, grudgingly he said that my upbringing had been as good a preparation as any for life in the other place.
	To be serious, much has changed since those days, most of it for the better. Public attitudes toward mental health have changed enormously, led I like to think by government and parliamentary action, and certainly reflected in Westminster today. There is a limited amount that the Government can do to influence public attitudes, and there is regrettably a very long way to go. In many ways, although progress has been made over the past 50 years, the glass is at least half empty. One in four adults during their life is traumatised by anxiety, depression, OCD, schizophrenia, dementia or another mental health condition.
	The report of the noble Lord, Lord Layard, published by the LSE, sets out some stark evidence. Mental illness is now nearly half of all ill health suffered by people under 65 and it is more disabling than most physical disease. Yet only a quarter of those involved are in any form of treatment. The report of the noble Lord, Lord Layard, also pointed out that 23% of all ill health in the UK—the largest single cause of disability—is mental ill health, yet only 11% of England’s annual secondary care health budget is spent on mental health services.
	My noble friend set out some of the costs—£100 billion a year, including 70 million lost working days, additional welfare benefits, lost tax receipts and the cost of treating
	avoidable illness. No price can be put on the suffering of those involved. Most of the millions of people suffering from depression, and children with behaviour problems, received no treatment, despite NICE’s recommendations. I hope that the Minister will be able to indicate how she thinks local authorities and clinical commissioning groups will deal with mental health care commissioning plans in the future.
	There is, of course, support for the glass half full view of the situation. Premature death of people with serious mental illness has declined, although it is still too high, particularly for schizophrenia sufferers—20 years. The quality of life of many mentally ill people has improved, as has the experience of healthcare. The Royal College of General Practitioners has committed to making improved care for people with mental health problems a training priority. I well remember as a child accompanying my father in his car as we followed the tail lights of general practitioners in rural Lincolnshire on domiciliary visits. Perhaps this will not have to happen so much in future, and reference to community health teams will be quicker.
	I do not doubt the good intentions of the Government and I pay tribute to the recent work of Jeremy Hunt, Norman Lamb and Simon Stevens. The Government have legislated for the first time for parity of esteem between physical and mental health. The intention is that most patients needing a talking therapy will be guaranteed treatment within six weeks, with a maximum wait of 18 weeks, and that patients experiencing their first episodes of psychosis will receive treatment within two weeks. Let us hope that these aspirations result in action—fine words butter no parsnips.
	The children and young people’s mental health and well-being task force has been established. The mental health crisis concordat has been signed by 20 national organisations. The Government have announced that everyone who receives mental health care should have a named, accountable clinician. Mental health has now been made part of the new national measure of well-being so that it is more likely to be taken into account when government departments are developing and implementing policy.
	My late father was one of the pioneers of day care. I am not sure that, seeing the outcome of care in the community in some of our inner cities, despite the deep commitment of carers, social workers and health workers, he would be convinced that an adequate solution has been found. What is required is a holistic approach, co-ordinating social care, general practice, liaison psychiatric and mental health specialist organisations, housing and education authorities and prisons. What we need is not just talk in Whitehall but action.
	The Health and Social Care Act for the first time in statute places a duty on the NHS to promote research. It is in the context of research that I turn to schizophrenia. I pay tribute to the work of charities such as Rethink, Mind and SANE—Schizophrenia, A National Emergency —founded and so ably run for many years by Marjorie Wallace, and of which I was a director for some time. There is now a schizophrenia audit, and depressing reading it will make.
	The exact causes of schizophrenia psychoses are unknown. They are among the commonest and most serious mental health conditions. Only one in 10 people who are diagnosed with schizophrenia is in work. Stigma still attaches to the condition. The human cost is colossal, the financial cost in terms of resources used is enormous and the distress to sufferers and their families is inconceivable. Schizophrenia affects about one person in 100 at some point in their life. It is estimated that it costs the UK taxpayers about £2 billion a year in care and treatment, together with the vast personal cost, both financial and in terms of suffering, for patients and family members. The global drugs bill alone is estimated to be £12.5 billion a year, not including hospital stays.
	So where are we now? Last year the Harvard Gazette published an article saying that there had been little innovation in drug development for the treatment of schizophrenia in more than 60 years. It went on to report on efforts to identify,
	“more than 100 locations in the human genome associated with the risk of developing schizophrenia”.
	The hope is that this might lead to the development of new drugs. Despite the pressing need for treatment, medications currently on the market treat only one of the symptoms of the disorder—psychosis—and do not address the debilitating cognitive symptoms. Treatment options are limited because the biological mechanisms underlying the illness have not been understood. The sole drug target for existing treatment was found serendipitously, and no medications with fundamentally new mechanisms of action have been developed since the 1950s.
	Great work is going on in the United States, financed by foundations and philanthropic donations, and there is an international project on genomes. On this side of the Atlantic, mental health has always been a poor relation in the charitable sector, with the exceptions of Alzheimer’s and autism. Mental health charities will not, in the foreseeable future, be able to compete with physical health charities, such as those devoted to cancer. That puts the Government in the firing line. The Institute of Psychiatry at King’s College London has been given £5 million for a project, but nothing will come from that, I understand, for a decade. So there we are: little progress over 60 years.
	I hope that the Minister will give me some comfort that the Government understand the urgency of further research into the causes of schizophrenia psychoses and the crucial role of the Government and the NHS in promoting it. Mental health has been described, with justification, as the Cinderella of the NHS—but let us remember with hope that Cinderella had a happy ending.

Lord Storey: My Lords, I am very grateful to my noble friend Lady Tyler for securing this debate. With three children in every classroom experiencing mental health problems, teachers need the right training and support to identify issues early and ensure that young people get the help that they need to recover and thrive. I would like to use my time to focus on mental health care and support in schools and on the
	creation of an ethos that does not ignore mental health problems but has the readily available resources and support to help children and young people proactively. Making such support available and accessible will not only be life changing for the pupil but head off later problems and lead to later savings in human and financial costs.
	A recent survey by CentreForum, as part of its mental health commission, concluded that 54% of head teachers found,
	“mental health services ineffective in supporting pupils”,
	while, at the same time, mental health issues are on the rise in schools. Confidence in child and adolescent mental health services, or CAMHS, was even lower among head teachers at pupil referral units, at 37%, and at special educational needs schools, at 43%. Sixty-five per cent of schools do not assess the severity of mental health needs among their pupils, yet where such screening tools are available 85% of schools reported it to be effective.
	As the Deputy Prime Minister rightly said,
	“Schools would never ignore a child with a physical health problem, so the same should be true of mental ill health too”.
	He went on to say:
	“Early intervention is crucial in tackling mental health problems”.
	So early identification and the provision of effective support systems are paramount in dealing with mental health problems. However, two-thirds of local authorities have cut their child and adolescent mental health services, and, unfortunately, the largest cuts have been to early intervention services.
	We need to provide alternative solutions which benefit families and young people affected by mental health problems and which take into account the existing responsibilities of teachers. For example, the Well Centre in Streatham, south London, provides drop-in one-to-one counselling, structured therapy, peer group work and digital services. Since CAMHS budgets have been reduced, we must look to investing in alternatives, such as linking up schools with these youth health centres in order to reach out to young people who may not have the confidence to ask for themselves.
	As a Government, we have been successful in introducing free childcare for increasing numbers of disadvantaged children, implementing education, health and care plans to enable quality and consistency for all young people with special educational needs and providing for further integration of crucial services that affect the well-being of children from birth throughout their education. However, mental health care for under-25s still makes up only 6% of the overall NHS mental health care budget. We must therefore continue to work towards preventing the suffering of those children with emotional, behavioural and psychological problems.
	I believe this can be achieved by creating the conditions that allow for early diagnosis. It can also be achieved by addressing the factors that can contribute to the stigmas surrounding mental health and maintaining high standards of mental health services for every child and family. It is our responsibility to enable every child to receive the best possible start in life. The only way that we can safeguard this right is by ensuring that education and healthcare services are equipped to
	tackle the underlying causes and contributory factors of mental illness. In doing this, we can help pave the way for improved physical and mental health for our children and, further still, support opportunities for all young people to learn effectively.
	We all believe that education and care for young people should provide the best start in life for every child, regardless of their background, their living circumstances or the socioeconomic status of their parents. Over the years, we have seen that early years and childhood experiences can have profound and long-lasting consequences for an individual’s health. We know that the life chances of a child are greatly influenced between the ages of three and five, and that their future chances are often predicated on their development in the first five years of life. If undiagnosed, mental health problems can continue to affect young people throughout their life, affecting their personal development, educational attainment and overall well-being.
	During my time as a head teacher, it was often clear to see that children from disadvantaged backgrounds were arriving at school, on their very first day, already a few steps behind their more fortunate peers. This had severe implications for their learning capacity, their ability to interact with classmates and even their literacy and numeracy attainment levels. While we tend to presume that such disadvantage is primarily caused by social and material circumstances such as poverty, family structure and demographics, all too often we neglect the role that mental health plays in child well-being. Yet around one in 10 of the nation’s children are affected by mental health issues, with significantly higher levels evident in certain groups of young people.
	Many education providers, parents and children alike find themselves confronted with the challenging realities that are presented by mental health care provision, and teachers are increasingly placed under considerable pressure to take responsibility for such demands. It is vital that education, youth services and healthcare providers have the capacity to work together in identifying mental health problems at the earliest possible point, in order to offer early diagnosis and professional, collaborative support.
	Furthermore, early diagnosis and support for affected children and families can significantly reduce costs to society in the long term, as well as empowering those who are affected to help themselves. Targeted interventions and the provision of integrated services at an early age are key strategies that have been proven to help reduce low educational attainment, unemployment, crime, and anti-social behaviour in the long run. The benefits of interventions during the early years of childhood are therefore realised both in the short term and over the entire life course of the child. As such, we should see the provision of mental health care in the foundational years as a valuable investment.
	We need to look specifically at the treatment of mental health for young people, and make sure that this treatment is accessible to high-risk groups. We need to ensure that there are flexible, sustainable and workable plans in place for young people affected by emotional illness from birth, and that care continues to be accessible throughout their lives.
	Finally, we need to cut right to the core of the issue, and act on the advice of medical professionals who emphasise the influence of perinatal mental health on a child’s upbringing. If mental health problems are identified and treated quickly, efficiently and effectively, many of these serious long-term human and economic costs can ultimately be avoided.
	I thank noble Lords her#e for their dedication in debating the importance of mental health care provision, and urge us all to consider further investment and accessibility in services for young people, as a crucial way in which we can prevent emotional disturbances from affecting the life chances of children from all walks of life. It is reassuring to see the progress that we have made in firmly placing mental health care provision on the agenda, and I look forward to seeing the Government, local authorities, trained professionals, and parents continuing to uphold the highest standard of care for young people.
	As Dame Sue Bailey, chair of the Children and Young People’s Mental Health Coalition said:
	“School is a critical environment where young people should be able to flourish across all domains of their lives. The gaps and concerns this report so clearly identifies reinforce the need to provide young people with the help, support and self-empowerment to develop and maintain resilience to stay mentally healthy in order to achieve and develop to their full potential”.
	I say, “Hear, hear”.

Lord Suri: (Maiden Speech) My Lords, I would like to thank all noble Lords on all sides of the House and the staff of this House for their immense kindness and friendliness in making me so welcome to this honourable establishment, navigating me through the protocols and giving me advice and guidance to enable me to fulfill my new role in this House. In particular, I would like to express my heartfelt gratitude and thanks to my supporters, my noble friends Lord Popat and Lord Leigh of Hurley, for introducing me to your Lordships’ House.
	Little did I know back in 1974 when I emigrated from Kenya to the UK that I would be bestowed with this great honour to work alongside your Lordships to continue contributing towards building a cohesive multicultural society in this country. I am humbled to join this House and family, which strives to represent the diversity of the population in this great nation. I am the second turbaned Sikh who has been elevated to the upper House. This great British institution has taken a praiseworthy step by bringing into its fold people of different faiths.
	I have spent all my working life as a businessman, with a career that started in Kenya as an importer of educational supplies. This was the start of my liaisons with United Kingdom, dealing with long-established British publishers. In 1974, having decided to migrate with my family to the United Kingdom, I pursued my business ambitions and challenged myself to a new business venture. I decided to enter into the fashion accessories trade, and much to my disbelief I encountered a harsh reality not previously experienced. The estate agents who offered me business premises to rent strongly advised me not to be the front man in a fashion
	accessories boutique as customers would not be forthcoming. Instead, my wife was recruited and she ran our boutique full time while I ventured onwards looking for further trading opportunities.
	We were determined to stand on our own feet and to earn our living without committing to the state for benefits. In 1977, I established a wholesale fashion jewelry and accessories business, and through its success I built up a sound property portfolio. The company is still trading strongly.
	Through my selfless and entrepreneurial approach to business, I have always remained actively involved with many charities, social action projects and social initiatives. This is in keeping with my firm belief that people should contribute back to society to help others in less fortunate positions. Service to charitable and voluntary works has always been deeply rooted in my ethos on life. Service to mankind and praying for the welfare of all is one of the principal pillars of the Sikh religion.
	I have been treading on this noble road to serve others from a very young age. Over the years I have championed community work and have held postsincluding justice of the peace, general commissioner of income tax, serving on the Middlesex Probation Committee and the Home Office Advisory Council on Race Relations, being a member of the board of visitors of HM Prison Pentonville and mentor to the Prince’s Trust youth business trust.
	I thank my noble friend Lady Tyler of Enfield for putting down the Motion for today’s debate on the importance of mental health care provision. Good mental health, as well as good physical health, is essential in enabling us to contribute to the socioeconomics of society. The relevance of today’s debate endorses over five decades of my contributing to the community, voluntary services and charities, starting in Kenya and continued in Britain with unremitting devotion.
	During my involvement as a voluntary associate at HM Prison Wormwood Scrubs, prior to commencing my voluntary career in probation and magistracy, it was evident that poor mental health and the lack of mental health care provision hindered people from making the journey to recovery. I would like to share with your Lordships aparticular case where I supported a fellow Sikh who was imprisoned for having committed murder. This individual, who I will call Tej, which is not his real name, was further isolated in this environment through lack of communication, as he was not literate and unable to converse in English. Tej was fluent in his mother tongue Punjabi, which limited his interactions and intensified his isolation and sense of hopelessness, contributing to his depression and placing him at a high risk of suicide.
	Through my weekly visits, we established a rapport. Over time, Tej was persuaded to join literacy classes in the prison, which reduced some of the isolation and frequency of suicidal thoughts. Through continual support, Tej was transferred to a prison nearer to his home town in order to rebuild his relationship with his family, who had severed all links with him.
	My work within the prison environment led me to visiting the young people at Feltham young offender institution. These young men were institutionalised as
	a result of their criminal activities, with an outlook of further poor outcomes in the future, and once again the state of their mental health contributed to the sense of despair and low aspirations. It could be said that the young people were like tender green shoots waiting to be trained along a framework that would build on their aspirations. They would acquire new skills and knowledge through education, which would be utilised in a productive way to reduce the cost to society.
	It has been important to me to have put my business skills into the field and mentored young people through the Prince’s Trust youth business trust, sharing my knowledge and experience of starting businesses, thereby giving them the tools to take the first steps in building a new life and contributing to their community but also to the economy of the country.
	Education has a multidimensional impact on every member of society and should be for all to take on board as a lifelong journey of learning, discovery and character building. In 1956, I had the privilege of meeting the President of the Republic of India at that time, Mr Sarvepalli Radhakrishnan, who was visiting Kenya to open the Mahatma Gandhi academy. In his speech, he emphasized that, although he was an academic, philosopher and statesman, he still considered that the world was his school. This analogy has influenced my thinking on education, which has brought me here today. I am sure that the provision of mental health services will remain high on the agenda of this House.

Lord Patel: My Lords, it is a great pleasure on behalf of the whole House to congratulate the noble Lord, Lord Suri, on his maiden speech. As he mentioned, he is the second Sikh to enter the House of Lords. He has also represented 450,000 Sikhs through his honorary secretaryship of the Sikh forum. No doubt, he brings his experience and wisdom from that time of representing Sikhs who contribute so widely to this society. He evaluated the many contributions he has made to the wider society in faith and commerce. He has also been a magistrate for over a decade, so he has many talents. Today he has demonstrated his commitment to mental health and his experiences in supporting prisoners. We welcome him to the House and look forward to hearing from him on many occasions.
	I am going to concentrate mainly on what parity of esteem means. I declare two interests. I am an honorary fellow of the Royal College of Psychiatrists, not because I have contributed much to mental health but for reasons I do not understand. The second is why I am interested in parity of esteem. Some noble Lords will remember that, during the debate on the Health and Social Care Bill 2012, I spoke on an amendment to give mental health parity of esteem. I was the third name on the amendment. The first name was that of the noble and learned Lord, Lord Mackay of Clashfern, and the second was that of the noble Baroness, Lady Hollins, one of the most respected psychiatrists in the land. Neither of them could attend that day and it was by chance that I called a vote which was won by four votes. Parity of esteem is now in the statute because of those four votes and the fact that the other place did not overturn it, presumably because of the wisdom of the coalition Government—I emphasise coalition.
	Much has been said in the past two years about parity of esteem. It has almost become a slogan. Whenever anybody speaks about mental health, whether they work in the mental health field or in health services generally, they talk about parity of esteem. It means different things to different people, but it probably means nothing at all to the public, the patients and their families. Turning the slogan into the practicality of what it should be will make the families and patients feel what parity of esteem for mental health is.
	The duty to ensure parity of esteem was enshrined in the Health and Social Care Act 2012, by securing improvement,
	“in the physical and mental health of the people of England, and … the prevention, diagnosis and treatment of physical and mental illness”.
	This duty provided a legal backing for the commitment to parity of esteem within the Government’s 2011 mental health strategy, No Health Without Mental Health. However, parity of esteem in mental health refers to a broad range of issues which reflect the role of mental health across all the different areas of our lives. “Parity” therefore refers not only to equivalent levels of funding for mental health but to a whole range of areas which affect our mental health—in and out of mental health services. Furthermore, parity of esteem needs to address “parity within parity”. By that, I mean the inequalities within mental health in terms both of the differential prevalence of mental ill health within marginalised groups and of achieving fair and equal access to services.
	Parity of esteem and its applications may come in different forms. When we look at parity between physical and mental health, we see a persistent mortality gap between people with a diagnosis of bipolar disorder or schizophrenia and the general population, as has already been mentioned. Measuring the parity gap may focus on the excess mortality that patients with mental ill health suffer. They die 15 to 20 years earlier than those who do not have mental ill health. The parity measurement gap may also refer to the burden of disease. One-quarter of the NHS disease burden and disability is due to mental health.
	The parity gap can also be measured by the treatment gap; that is, the number of people who may have a condition, but do not get the treatment for it. It is as low for common mental disorders as 24%, compared to 85% for a broken hip. The parity gap in treatment is therefore considerable.
	In cases such as schizophrenia, the gap in the general population is widening among certain groups. Problems such as diagnostic overshadowing mean that the physical health needs of people with mental health problems are not sufficiently investigated. Only recently have waiting time targets been introduced for psychological therapies, already mentioned, in contrast to long-standing physical health waiting times. In mental health, we currently see one in 10 people waiting up to a year to receive treatment, particularly for psychological therapies. It is still hard to get the full range of NICE-recommended psychological therapies—only 15% of people are offered the full choice of approved therapies.
	Mental health must also have an equal footing with physical health in public health strategies. There is clear evidence and a convincing economic case for
	investing in public mental health. Parity in funding has already been mentioned. Mental health has been historically underfunded compared to physical health. At present mental health accounts for only 13% of NHS spend on health, despite accounting for 23% of the burden of disease. Mental ill health is also the single largest cause of disability in the UK. Investment in mental health research is key to advancing parity of treatment for mental health.
	Despite mental health problems affecting one in four of us, funding for mental health stands at less than 6% of all health research funding. A commitment to parity in funding must be consistent across government and health services. In 2014 Monitor announced a funding decision to cut mental health services by 20% more than NHS hospital trusts. I know that Ministers did not approve of that, or like it, but none the less, the funding was cut. Reports found that 77% of clinical commissioning groups have frozen or cut their children and adolescent mental health services budget between 2013-14 and 2014-15, alongside 60% of local authorities in England having cut or frozen their budgets since 2012.
	Mental health services must see real-terms funding increases to be equipped to meet increasing demand and unmet needs for both adults and children. Parity within mental health is essential to ensure that anyone who experiences a mental health problem has fair and equal access to treatment, especially among marginalised groups. This includes adapting services to make sure that they are inclusive of all. There are no hard-to-reach people—there are only hard-to-reach services.
	One way to address this is through the coproduction of services. Outcomes for people with complex needs and from minority-ethnic communities are unacceptably poor. This also means that mental health services should be appropriate for people across the life course, from children to later life. Young people need to be given the skills to address life’s challenges with the confidence to manage their well-being, and older people need services that are accessible and appropriate. Health inequality increases the likelihood of experiencing mental ill health, and addressing inequalities can promote the population’s mental health.
	Parity and stigma is another issue, which some noble Lords have already mentioned. Nine out of 10 people with a mental health problem experience stigma and discrimination. It is essential that the work of the Time to Change programme continues to improve public and professional attitudes to mental health. It is essential to eradicate the stigma surrounding mental health in professional health settings, as stigma affects the esteem in which professionals are held.
	I have two questions for the Minister. First, what steps are the Government taking to reduce the imbalance in the provision of publicly funded research into mental health? Secondly, what are the Government’s plans to ensure that mental health services are appropriate for people across the life course?

Lord Farmer: My Lords, once again the noble Baroness, Lady Tyler, has secured a debate of vital national importance, for which I thank her. I take this
	opportunity also to congratulate my noble friend Lord Suri on a very fine contribution to this debate. I am aware of the considerable expertise that lies within your Lordships’ House on the issue of mental health, so it is with some humility that I approach the subject—but also with a conviction that there are neglected issues, and it is at these that I will pitch my comments.
	My overriding concern is with the drivers of our high levels of mental disease—I use that term deliberately. When a nation as great as ours has prevalence rates of one in six adults at any one time suffering profound mental distress, as well as one in 10 children and young people, this surely reveals an underlying and widespread societal dis-ease. Mental illness does not just happen: very often there are preventable causes, and this is where a new wave of public health effort needs to focus.
	We have just heard from the noble Lord, Lord Patel, that mental health is the single largest cause of disability in the UK. It is responsible for a quarter of the disease burden and 13% of the NHS budget. Although that disparity will, I am sure, be the concern of others here today, I would ask us simply to pause for a moment and consider how much is already being spent, and how much human misery it represents, rather than simply asking for more money. Moreover, it is a fraction of the overall cost to society, estimated by the Centre for Mental Health at £105 billion every year. We simply cannot afford these eye-watering costs and loss of human potential, so I emphasise the importance not just of treating mental illness but of preventing it from occurring—or recurring.
	It is now widely accepted that we need to adopt a bio-psycho-social model to understand the causes of poor mental health. To put it more simply, it is not just about genetic predisposition, it is also about the kinds of families and communities people grow up and live in, the character of schools and workplaces, and societal attitudes. If we are serious about preventing mental dis-ease, we have to step back and ask some fundamental and searching questions about the kind of society we want our children and grandchildren to be born into, grow up in and grow old in. First and foremost, it should be one where the unique human worth of every individual is appreciated and which places a very high premium on relationships. With this as a backdrop, I will now unpack what is meant by a bio-psycho-social model, highlight key issues in these three areas where we need to see profound cultural change and recommend how this might be achieved.
	First, in terms of biological drivers, drug misuse can be both a cause and effect of mental illness. The British Journal of Psychiatry reports that 80% of first-episode psychiatric disorders, schizophrenia or schizophrenia-like illnesses occur in either heavy or dependent cannabis users. Individuals using cannabis are doubling their risk of developing schizophrenia. This undeniable risk to mental health is why I am so strongly opposed to legalising cannabis. We need to send a clear and unambiguous signal to our young people that drug use, which many of them think is somewhat cool, is strongly implicated in the development of mental health problems—which everyone would agree are deeply uncool.
	Similarly, I consider it highly appropriate for the Government to fund information campaigns such as Time to Change, which the noble Lord, Lord Patel, just referred to, which address the stigma of mental ill health. This deters many people from coming forward for treatment when problems are at an earlier and possibly more manageable stage. Stigma has to be seen alongside the second area of social factors, which include isolation and loneliness, unsupportive and hostile communities, poor housing, inadequate healthcare, financial poverty and sexual or racial discrimination.
	The risk of psychosis among Black African-Caribbean groups is seven times higher than among the general population. They are more than twice as likely to commit suicide and three times more likely to be admitted to hospital. They are more than 40% more likely to be sectioned—in other words, detained without their consent under mental health legislation.
	Prevention of hospitalisation is a worthy goal for financial as well as therapeutic reasons. I will describe how voluntary sector organisations can do just that. Recent polling found that, of those with experience of hospitalisation, more than half did not feel the settings and facilities aided recovery; 44% felt that the treatment they received was fairly or very ineffective; and 14% felt very unsafe. People who feel unsafe in hospitals are not necessarily simply nervous types. I have heard how returning soldiers with post-traumatic stress disorder consider UK hospital settings more dangerous than the Iraq or Afghanistan front line. It should not be possible to spend one’s days in a mental health ward, hunched up on the floor against the wall, alone with one’s troubling thoughts, while nurses busy themselves with bureaucratic tasks. One study found that only 16% of patients’ time was passed in what is loosely termed “therapeutic interaction”. The remaining 84% was characterised by a distinct lack of purpose.
	I understand how much pressure mental health professionals are under. The Mental Health Act Commission found that nurses were unhappy about being too busy to develop therapeutic rapport with patients. The commission concluded that all hospital wards caring for detained patients should ensure that they have “protected engagement time” with nursing staff. I endorse that recommendation. Everyone needs to feel that they are significant, that they are worth spending time over and that they belong.
	This leads me to a third category of psychological factors. These include insecure attachment to parents in infancy, sexual or physical abuse in childhood, inadequate, neglectful or abusive parenting and being bullied or harassed—in other words, continually feeling unsafe. This is possible even in the workplace, because of one’s own line manager. Bereavement, lack of any close confiding relationships and family breakdown are also factors. I keep promising myself that I shall give a speech in your Lordships’ House in which I do not mention family breakdown. It is getting very difficult to do that because of its myriad, knock-on effects.
	There is a strong evidence base about the impact on a child of losing one parent, which sadly goes beyond the financial or emotional and reaches into the heart of this debate. According to Professor Richard Whitfield, for a child to surface, somebody needs to be crazy
	about them. Morgan and Fearon, researchers at the Institute of Psychiatry, found that family breakdown and early separation from a parent had a clear effect on rates of psychosis in the African-Caribbean population, where there is a higher likelihood of growing up without both birth parents. Insights such as these make it even more imperative that we address family instability, which affects poor communities of whatever ethnicity particularly badly.
	Honesty requires us to admit that one’s birth family can be at the root of mental health problems. The first onset of mental health problems is commonly in childhood or adolescence. Half of all lifetime cases have started by the age of 14. A prevention agenda has to make parenting support a major priority. There is a great prize in helping families repair and its members become a resource to each other. Families can also be at the heart of the solution. Recent polling found that more than half the people with mental health difficulties received “a lot” of help and support from their families. This was more than those who cited their GPs and three times as many as those citing psychiatrists. We urgently need better family functioning to be included in the national Public Health Outcomes Framework. This would mean that local authorities had to ensure that couple support and family therapy were offered as standard—for example, in the family hubs for which I am pleased to hear there is growing cross-party support.
	There must also be greater recognition of the role that supportive communities can play because not everyone lives in a family. The black-led churches are on the front line of preventing mental ill health. Organisations such as the African Caribbean Community Initiative in Wolverhampton are helping to keep many black people out of hospital by inspiring confidence in mental health professionals that their patients are safe in their hands.
	That is what we all need for well-being and good mental health—reliable relationships, whether in families, the workplace, healthcare settings, faith communities or during our retirement years. The Government have a clear role to play by pursuing policies that will strengthen rather than undermine these relationships and the innate desire and ability that people have to look out for one another. I am my brother’s keeper.

Lord Addington: My Lords, the first and very pleasant duty that falls to me today is to welcome from these Benches—from this part of the coalition—the noble Lord, Lord Suri. A good start has been made and we look forward to what is to follow.
	When I put my name down to speak in this debate, it was because of something which is blindingly obvious to somebody such as me who has dealt with disabilities for many years. Somebody who is disabled is likely to undergo slightly more stress than somebody who is not. Stress seems to be one of the key factors, whether it comes from family, or social background. With disability—that is, not being able to function—there is going to be more stress and there are probably going to be slightly more mental health problems there. It is a little bit of a no-brainer.
	However, many of the speeches today have touched upon that. I always regard people as being a cocktail of a series of events, circumstances and chance and all these things come together in individual people, making them slightly more likely to go in certain directions or react in certain ways. If you are a person with a disability, who struggles to access certain parts of society or to communicate, or to achieve as your peers would, it is an almost dead cert that you will be slightly more vulnerable and there is a slightly higher probability that mental health problems will occur in your life. Virtually all the reading I have done backs this up, and everyone who has spoken to me has said so.
	On the issue of dyslexia—the noble Lord, Lord Farmer, might have said that he always talks about family breakdown; I am trying to find a subject where I cannot find an aspect on dyslexia and my connection to it and I have failed so far—it is well known that dyslexics get slightly more stressed in the classroom and that mental health problems will be that little bit more common among them. However, they are not the only group. When it comes to autism, 70% of young autistics are reckoned to have a mental health problem. That 70% equates to 1% of the population. The on-costs of not dealing with this in the best way are massive. To deal with just those two groups at first, most of those have economic capacity and the capacity to work, but that will be greatly reduced by not giving them support and help throughout. By not taking action, we are effectively creating that little bit more of a burden or drag on society and making people’s lives more unpleasant.
	All those whom I have spoken to in this field say that there is one problem that the medical world—and, indeed, the rest of the world—has in dealing with this. When they see a person who has a disability, whether obvious or hidden, they tend to see the disability first rather than think about what might be going on behind it. I remember that we had a long debate in this Chamber about how the deaf, or British Sign Language users, access the health service. How much more difficult is it for a doctor or a professional to establish that mental health provision is required when they cannot understand the person, who has to be translated through somebody else? There are sometimes difficulties there, so how do we address this?
	If we are serious about taking this very sensible and good step forward of giving parity to those with mental and physical health problems, the first thing we must do is surely to ensure that all those in the health service are at least aware that this possibility is there. I am talking about everybody not becoming expert and trained but being aware that there might be a problem, which they should assess and move on from. A degree of awareness can be achieved fairly easily, simply by stating, “By the way, in certain groups certain types of conditions are more frequently occurring”. Once again, that is a no-brainer, but what is required to move you on?
	Regarding the education sector, my noble friend Lord Storey mentioned how the Department for Education deals with mental health. In education, we have for a long time dealt with special educational needs, but most of the problem that we have is in identifying
	them and getting the system to recognise them. I do not say that the Department of Health is going to become any worse but without training, without pushing to make sure that it is kept under surveillance to do so, it will not be any better. That is because it will think—and it may be right—that it has enough to do as it is in dealing with the duties in front of it. That will be so unless you place a duty on that department to become aware or find out and make sure that, when it does not, it must report back the reason why. That is both to reinforce the fact that it is a duty and so that the systems are in place to make sure that it does not happen again. If we do not undertake this type of activity, we will reinforce this cycle of people who are underachieving.
	We will not address the selfish interest of society properly unless we become aware of this. We will have a whole section of our society who we are encouraging by saying, “You should go out to work and become fully active”. Indeed, we are making that a legal duty; all Governments in the last few years have done this, saying, “You should get out and earn. We don’t want you sitting at home”. But unless we make sure that they are supported the whole way round they are going to fail in this, effectively because they have no option.
	If we look at other areas where bad mental health is prevalent and disabilities, often hidden, are common, we could look at prisons. I thought that I might say a few things on that, but I looked at the speakers list, and then across the Chamber, and saw the noble Lord, Lord Ramsbotham. Whether or not he chooses to take a bite out of this particular apple today, I will always defer to him on that issue, but we should look to the examples of how we get such “co-morbidity”, which I think is the correct term here—personally, I think the word means that you are dying twice and quickly, so perhaps we should say “co-occurrence”. For an example of where co-occurrence leads to failure and expense, you need look no further than prisons. This is particularly true of conditions such as autism and other hidden disabilities. In all the cases at which I have looked, not looking at the whole person or beyond the initial aspect will lead you into trouble.
	I am in grave danger of reciting all the facts that I have about the problems in these areas, such as that people with a learning disability were traditionally seen as not being worth indulging with a talking cure —because it would not do them any good because you cannot help them anyway. However, they can become more independent and they can get out there. Unless we address the idea that we give all groups in this sector as much help as we can, we will fail. In failing, we pass on costs to society and to those in families who end up looking after these people.
	Carers have a high occurrence of mental health problems. They are under stress. We must start to cut this Gordian knot or break the circle—the clichés roll on—and address this by saying that you must look for this problem, think of a strategy and get into the system some awareness of those who are using it. We must also make sure that the medical profession is prepared to take advice on this subject from outside. Unless we do these things we will not ultimately get the full benefits of a very sensible strategy. We must exercise
	our peripheral vision and think laterally on this, because it will touch every aspect of society. If we do not, the strategy will not work.

Lord Ramsbotham: My Lords, like other noble Lords, I congratulate the noble Baroness, Lady Tyler, on obtaining this debate and for the way in which she introduced it. I also echo her tributes to the Ministers Paul Burstow and Norman Lamb for their work in the mental health post. I agree entirely with her call for a cross-government mental health and well-being strategy, which has been long needed.
	When I saw the list of speakers, I knew that I did not need to say anything about learning difficulties and disabilities, as the noble Lord, Lord Addington, was there. Every time he stands up I realise that we are listening to someone who not only uses his experience wisely, but is worth listening to because of the practical things that he always adds. I also welcome the noble Lord, Lord Suri. I was very glad to hear him concentrate on elements of the criminal justice system, particularly Feltham. Not surprisingly, that is what I propose to do as well: concentrate on the criminal justice system.
	Before I do, I declare two interests, first as vice-president of the Centre for Mental Health, which has done a great deal of work in the reissuing, in particular, of carefully researched reports, which have provided everyone with a great deal information on the whole system and the problems within it. Secondly, I am chairman of the Criminal Justice and Acquired Brain Injury Interest Group. This is doing a great deal of practical work, and showing up some of the shortcomings in the criminal justice system in identifying and assessing the problems that people have, and what needs to be done about them.
	Echoing the noble Lord, Lord Goodlad, I should explain that I was fortunate enough before becoming Chief Inspector of Prisons to chair the hospital at Hillingdon, which had a very large and extremely well run mental health unit. The director said, “You must train as a lay assessor or otherwise you’re no use to this hospital”. I am extremely glad that he did because he gave me an insight on which I have based all my subsequent experiences.
	When I took over as chief inspector in 1995, I was extremely alarmed to find that healthcare in prisons was not the responsibility of the National Health Service. It seemed utterly absurd because people came from the NHS and went to the NHS. The staff were not NHS-trained, and I discovered that only 10% of medical officers in prisons were qualified to act as GPs in the National Health Service. I set out to try to do something about it. That aim was achieved in 2003, eight years later. I was very glad that we had quicker-minded people acting for the country during the Second World War.
	Fairly soon after that, in 1998, the Office for National Statistics published psychiatric morbidity figures for all our prisons. It produced the figure that the noble Lord, Lord Addington, cited: 70% of prisoners have one or more identifiable personality disorders. That does not mean that they are certifiable under the Mental Health Act, although at least 500 a year are, but it
	means that there is something wrong. If you can identify it and do something about it, that could mitigate the bad behaviour or whatever it was that led them to commit their crime. It has always seemed to me that the proper assessment of whatever mental health problems people come in with has been sadly missing. It has always been said that treatment in prisons should be the equivalent of treatment in the NHS, but unless the assessment is right, you will get no treatment that is worth the name. The importance of partnership in that is that time in prison is when various organisations could get to grips with whatever physical or mental health problems a person has and use the time to advantage. That must be a public health benefit when people are released.
	An improvement that came from the Health and Social Care Act was placing commissioning for offender services under NHS England. Having heard about it, I looked forward to the development of local health and well-being boards on which I hoped the criminal justice system would be properly represented. However, I am concerned about the inconsistency of these boards, and it worries me that they meet only quarterly. If they are to help the criminal justice system in particular, meetings need to be more frequent and consistency between what happens in one health and well-being board area and another needs to be developed.
	Having said that, like the noble Lord, Lord Goodlad, I welcome the foundation of the mental health and well-being task force. It is a healthy development in this area. I particularly welcome its children and young people sub-committee. The five all-party groups that are studying children and young people’s mental health and emotional well-being are going to meet the sub-committee. That is particularly relevant for one of my current concerns, which is that I do not think that all is well within the criminal justice system. I am currently very concerned that due attention is not being paid to the mental health needs of detained children. That is confirmed by the proposal to build a secure college for 320 of them under the age of 18 in which the emphasis is to be on education which, it is alleged, is the key to a reduction in reoffending. What is being proposed is totally at variance with the advice of those who have any experience of the characteristics, problems and needs of the children who will be sent there. The scant acceptance of this advice is reflected in the insistence by the Secretary of State for Justice that educational outcomes are more important than the selection of suitable staff. How wrong he is: staff are absolutely key to anything that is done.
	I have two other concerns. One is purely to do with the criminal justice system and the other with the linkage between that system and people outside it with mental health problems. My first concern is probation. There are 200,000 people currently serving community orders. Only 20% of CCGs believe it is their area team’s role to commission healthcare for those on probation. We have just got that figure through the Freedom of Information Act. Only 1% of CCGs are currently directly funding general healthcare in probation; 40% have nothing to do with it; the remainder have some association with it. Only 6% of mental health trusts provide services for probation and the majority of that takes the form of a half-day advice clinic once
	a week. That is wholly inadequate and something must be done, somehow, to connect the Ministry of Justice and the Department of Health to improve support for those on probation, who have exactly the same characteristics as the Office for National Statistics showed in 1998 for those in prisons.
	My second concern is employment, which is absolutely key to the rehabilitation of any offender but is also crucial to the future well-being of people with mental health problems. Last week, I attended the launch of a report by the Mental Illness and Employment Task and Finish Group, which addressed the serious inequality of employment outcomes for people with and without mental health problems. It is a very good report and Norman Lamb spoke extremely well at its launch. I welcome the recent introduction of CCG outcome indicators on employment rates for people with mental illness because this will, at least, draw the facts to people’s attention. I welcome the Commissioning for Quality Innovation targets for supporting adults who are in contact with mental health services. This is an unresearched area and we need to do much more if we are really going to provide mental health services in this country that are worth the name.

Baroness Chisholm of Owlpen: I thank the noble Baroness, Lady Tyler, for initiating today’s debate and join your Lordships in congratulating my noble friend Lord Suri on his maiden speech.
	In my lifetime, mental health services have gone through a radical transformation, perhaps more than any other part of the health system. When I started nursing, people with mental health problems were usually treated in large institutions. Today, as your Lordships know, care is focused mainly in the community. Multidisciplinary teams care for people in their own homes. Admissions are in small specialist units and for those requiring long-term care there are small residential units. This is, of course, the way forward, but unlike most other health complaints, mental health has its own very special problems. When those with mental health issues suffer an episode, they require immediate attention. An appointment one week or even a few days later can be too late and lead to disastrous consequences. Acute in-patient service provision has remained a challenge throughout the country, as has community care. With people being treated mainly in the community, the number of in-care beds has decreased, causing an increased number of out-of-area placements at substantial cost to authorities and with lengthy travel, leading to extra cost to clients and their families. But there is good practice going on that is making a considerable difference in certain areas and I would like to share two of these with your Lordships today.
	I am closely involved with a charity called the Nelson Trust which has facilitated two women’s centres, in Gloucester and Swindon, treating clients with substance abuse. As the Corston report stated, more often than not these women have a history of mental health issues. The women whom we are seeing at the centres are those who have suffered trauma in their life, leading to depression, self-harming and personality disorders, and this in turn has led to substance misuse. Many of
	our clients have served custodial sentences and been in constant trouble with the police. When they are referred to us, the Nelson Trust can be their last chance to avoid a prison sentence.
	We have heard from the noble Lord, Lord Ramsbotham, about the importance of looking after people with these problems in our society. In July 2014, Theresa May delivered a speech outlining the importance of ensuring that people with mental health problems are identified and diverted from the criminal justice system into appropriate healthcare and support service providers. The psycho-educational group programme at the Nelson Trust responds to these difficulties along with emotional and practical support not only to the client but, more often than not, treating the whole family. This brings huge financial savings to the community and treats the multiple problems that mental health can bring under one roof. The centres are closely involved with the police, probation and healthcare professionals, magistrates and housing providers.
	In Cambridgeshire, our police and crime commissioner, Sir Graham Bright, facilitated a Cambridgeshire and Peterborough mental health crisis care concordat. This landmark agreement sets out how agencies that deal with people suffering from mental health problems will work together to support those experiencing a mental health crisis. Improved information-sharing, prevention and early intervention were just some of the commitments made in the declaration.
	Those are just two examples of joined-up thinking which has brought a difference in these communities to both those suffering from mental health problems and the professionals who come into contact with them. Implementing known good practice that already exists provides good integrated mental health care, saves time and money and expedites the care that can be available. The King’s Fund stated in September 2014:
	“Cultural change is as important as funding in transforming mental health”.
	How true this statement is.
	Mental health still carries a stigma, yet one in three of us will come into contact with mental health problems in our lifetime. It can affect people of any age, any socioeconomic group and is hugely destructive not only to those suffering mental health issues but to their families as well. We are at ease discussing other health issues, quite often intimate ones, but will rarely discuss mental health issues. This must change; mental health should be treated as a core public health issue so that it will be as normal for everyone to look after their mental health as it is to look after their physical health. The public health workforce must see mental health as one of its core responsibilities. The voice of the mental health community is finally being listened to and, as we are seeing today, the issues are being debated, but collaboration between commissioners, providers, service users, academics and clinicians and the justice system is still too rare.
	Mental health cannot be considered in isolation and can rarely be separated from physical health. Therefore, as with most practices within the NHS, it requires a joined-up approach involving multiple stakeholder groups. A reduction in the number of people across the UK developing mental health disorders is surely the only
	way that mental health services will adequately cope with future demand. The case for more preventive work is therefore undeniable.
	Arguably, the onus today is on GPs to run initial care and give treatment, instead of referring patients on to the appropriate professional. However, as one noble Lord has stated, some GPs have said that they felt out of their depth. Is this partly due to the downplayed role of psychiatric social workers, daycare workers and community psychiatric nurses? Could an acute episode be avoided if respite or suitable community care were more readily available when someone felt an episode building up, thereby saving considerable frustration and a feeling of helplessness for the client, as well as saving the considerable resources required for treating an episode once it reaches crisis proportions?
	These are an inadequate few words on a massive subject that affects people from birth to death, leaving in its wake a feeling of helplessness, fear, frustration and loneliness among all those it touches. We must feel confident that, when seeking help for mental health problems, the appropriate healthcare experts will be immediately available to give us the appropriate treatment and care in the appropriate place.

Baroness Janke: My Lords, I, too, am grateful to the noble Baroness, Lady Tyler, for initiating this debate. I shall focus on the significant numbers of people with multiple and complex needs. They might be street drinkers, homeless people, an aging drug-using population; people with wide-ranging mental health issues, including complex trauma histories; many women trapped in the sex industry with significant multiple needs; and young people, including 16 to 17 year-olds. They might be individuals with serious health-related needs and long-term conditions who have a range of complex needs, some of whom are at the end of their lives, as well as increasing numbers of people who are unable to be housed due to the complexity of their needs and the risks associated with their behaviour.
	These people often have at least three of the four needs areas: mental ill heath, homelessness, drug and alcohol misuse, and offending. They are also likely to have other significant factors such as: poor physical health, including long-term conditions; experience of complex trauma in childhood or early years; and experience of domestic abuse. This group is often the farthest away from services or only comes into contact with services when in crisis; they perhaps come into contact with the police, A&E or mental health crisis teams. In addition, gaps in services, or the way that services are provided, can mean that, in the worst cases, help is not available, or that people are passed round the system, having to deal with several different agencies—or, worse still, that they get into the revolving-door syndrome where they are constantly repeating their experiences and not receiving the support to ever move forward.
	Mental health needs in this area are often undiagnosed, undisclosed, untreated, masked and compounded by other needs. It is an area where people have problems that are often considered too entrenched or too complex and they have no one to turn to. It is an area where
	traditional ways of working are simply not working. It is understandable that many of these people feel excluded and without hope. The conventional services are not addressing their needs but are being used in an ineffective and costly way. People with long-standing mental health needs are not well served by repeatedly ending up in A&E or in police custody. As many experts have said, the services provided for those with multiple and complex needs have to change. Indeed, the noble Lord, Lord Patel, said today that it is the services that are hard to reach.
	I would like to highlight one project today that is particularly focused on this area of need; it is called the Golden Key project. The idea is that this golden key will unlock services. It consists of a partnership board, resulting from a Big Lottery Fund bid by a consortium of agencies working with Bristol City Council. The project helps people to drive their own recovery by providing support, by reconfiguring services, and by enlisting the help of people who have had the experience of living through similar issues and who have come through it to regain their own lives.
	The project is at an early stage. As I said, it is run by a broadly based partnership on which the full range of interested groups are represented, including agencies that provide services, commissioners, clinical commissioning groups, peer mentors who have real experience, business, and city leaders who are championing this project. Key elements include a group of 300 individuals who sign up to the project “walking the journey” with a lead co-ordinator at a pace that is right for them. At the heart of the scheme are the peer mentors, who bring their own lived experience to support, and to inspire hope. Golden Key agencies and services are pledged to work together to make services accessible and sympathetic to needs.
	Innovative aspects of this project include small personal budgets that encourage staff and their customers to think carefully about which practical measures might create early successes. There is a “telling your story once” website, with access controlled by the client, so that people do not have to repeat their personal information and story. One symptom of the current service is that an individual seeking support may have to tell his or her story to a range of different agencies. This website tries to bring services together and shape them to the individual who needs them. There will be a psychologically informed environments approach to deliver more effective services through a deeper understanding of clients’ needs. There will also be training and action learning to embed change.
	Very many of us are aware of this complex area of need and care about these most deprived and excluded people. It is essential that these people’s acute need is fully recognised and that we look at ways of building on national and international examples of good practice. Through this, we must find ways of unlocking the future for a group of people who often do not believe that they have one.

Lord Bradley: My Lords, I also congratulate the noble Baroness, Lady Tyler of Enfield, on securing this very important debate and on her very effective
	and wide-ranging opening contribution to it. I also congratulate the noble Lord, Lord Suri, on his excellent maiden speech. He will clearly be a very welcome addition to your Lordships’ House.
	Mental health has rightly risen up the political agenda significantly in recent years. It is timely to take stock of the current issues and policy developments that have taken place during this Parliament. I declare my interest as a trustee of the excellent Centre for Mental Health, which undertakes superb work in this area.
	Let us first consider further some background facts and figures. I make no apologies for repeating what many noble Lords have already mentioned. Mental health problems affect 23% of the population at any one time, the most prevalent of which are depression and anxiety at 17% of the total. As we have heard, the economic and social costs of mental ill health are estimated to be £105 billion annually. As the NHS Five Year Forward View points out, this is roughly the cost of the entire NHS budget. Mental ill health accounts for 23% of all ill health—more than heart disease, cancer and diabetes—and causes as much ill health among working-age people as all physical illness combined. Some 10% of children aged five to 15 have a mental health problem. Three-quarters of people with depression receive no treatment at all. A third of people with a long-term physical illness also have a mental health problem. This costs the NHS an extra £10 billion in extra prescriptions, hospital admissions and more expensive treatments.
	As we have heard, nine out of 10 prisoners have a mental health problem, and mental health research funding—as we have heard again—is appallingly low. As the organisation MQ points out, the scale of mental health research is not proportionate to the burden of disease. The spend on mental health research is just 5.5% of the total research spend in the UK, despite the fact that mental health problems, as we have heard, affect around one-quarter of the population in any one year. MQ further points out that a major challenge in the mental health funding landscape is that, in contrast to the other major health conditions, public funding of mental health research is virtually non-existent. For every £1 that the Government spend on cancer research, the general public invest £2.75; for heart and circulatory problems it is £1.35. For mental health research, the figure is 0.003p. I am not arguing against such public investment in other disease groups; I am simply putting mental health research in that broader context. Like the noble Lord, Lord Patel, I look forward to the Minister’s response on that point.
	Against that backdrop, what have been some of the key policy pledges made by the Government on behalf of those suffering with mental health problems, and what appears to be the current position on each? First, there are new access standards for mental health, which are clearly welcome. Announced in October 2014, they include, from April 2015, waiting-time standards for improved access to psychological services, and early intervention in psychosis services. The Department of Health’s five-year plan to improve access to mental health care pledged to follow this up with further standards, for example in urgent care and in child and
	adolescent mental health services. This must be completed to ensure that we have genuine parity of access to mental health care, as we do to urgent and elective care for a range of physical illnesses. There must also be comparable entitlement to NICE-approved interventions to ensure that there is no compromise on quality. Such entitlements are essential to delivering parity of esteem. However, I noted carefully the views of the noble Lord, Lord Patel, on that point.
	Secondly, on mental health care funding, data suggest, as we have heard, that NHS spending on mental health services has fallen in real terms each year from 2011 to date. This is putting services under great pressure, leading to disinvestment in effective interventions such as crisis resolution and home treatment, and placing extra pressure on hospital beds. It is even leading to bed closures where there is often already underprovision. Local campaigns, such as those in Waveney and other areas of the country, have been initiated to protect vital local mental health services. I would be grateful for the Minister’s views on that situation, as well as for his view on the Royal College of Nursing’s view that there are now 3,300 fewer posts in mental health nursing and 1,500 fewer beds than in 2010. Planning guidance recently published by NHS England asked CCGs to secure real-terms increases in mental health spending for 2015-16. It is vital that this is implemented and that accurate records are kept of spending on mental health services for adults and children.
	Thirdly, on crisis care, the crisis care concordat was published a year ago, as we have heard, and is welcome. It sets out the standards expected in all local areas. The deadline for localities to produce crisis care declarations has now passed. These should be followed up with local action plans to implement agreed measures. The tracking map shows that all areas have now made declarations but that few have action plans to go with them. It is unclear how local organisations will be held accountable for achieving progress and how it will be monitored. I hope the Minister will be able to elaborate on that point.
	Next comes liaison and diversion, in which I have a particular interest. NHS England recently announced the expansion of the national programme of liaison and diversion services to cover half the population of England. This is welcomed but we must ensure that it is extended nationwide by the committed-to date of 2017. However, there is also a need for CCGs and other commissioners to commission services to which people can be diverted to make the investment in such services as effective as possible. I hope that the Minister can reassure us on that point as well.
	Finally, on employment, the Government have recognised that the Work Programme is not offering adequate help to people with mental health problems, and they have invested in a pilot to trial the adaptation of the individual placement and support approach for people with common mental health problems. This work needs to inform the future of the Work Programme. I also commend the report that has been mentioned, published on Tuesday, on addressing the serious inequality of employment outcomes. It makes very clear recommendations on how to improve employment opportunities for people
	with severe mental health problems, such as schizophrenia, about which the noble Lord, Lord Goodlad, spoke so eloquently earlier.
	In spite of those initiatives, which are clearly welcomed, there remain many weaknesses and concerns. We have already talked about the real-terms reduction in funding and about the fact that people with mental health problems have been adversely affected by continued weaknesses in the work capability assessment and, in some cases, by the use the benefit sanctions. We have heard about schools being given little support in promoting mental health and the removal of well-being from Ofsted inspections. We have also heard of the major concerns in children’s mental health services, which have experienced particularly large cuts. Last year, two-thirds of councils and three-quarters of CCGs cut or froze CAMHS spending. A recent Parliamentary Answer showed that the aggregate PCT/CCG expenditure on CAMHS fell in real terms from £758 million in 2008-09 to £717 million in 2012-13, and I suspect that it has continued to fall. The position is exacerbated by cuts in youth services, many of which have a positive impact on well-being and prevent the emergence of later problems.
	Finally, what should be done to ensure that these situations are addressed? This afternoon we have heard many good examples of new initiatives. We must continue to explore ways of making the NHS constitution fairer, including a wider range of access standards and entitlements to NICE-approved interventions. We must consider revising payment systems for all mental health services to put mental and physical health on an equal footing. We must ensure that the NHS, public health and social care outcomes frameworks and the quality and outcomes framework for GPs properly represent mental health priorities. We must invest in cost-effective interventions—which are currently undermined by a postcode lottery—for, for example, perinatal mental health care and parenting programmes, and, crucially, we need early intervention in psychosis and individual placement and support.
	My time is almost up but that list is not exhaustive. The quality of this debate shows how many initiatives people understand and want to progress through the development of mental health services. Whether we are talking about adults or children, they need and deserve that support, and I hope that this high-quality debate will help to progress that agenda.

Baroness Jolly: My Lords, I thank my noble friend Lady Tyler for tabling the Motion for this excellent debate. It has really been a series of mini-debates. We have had experts of all sorts bringing their experience to bear on subjects such as parity of esteem, maternal health, dual diagnosis, children and young people, prisons and public health, to name but a few.
	Mental illness can emerge at any age and can have highly significant impacts across much of the life course for the individual, their family and the community. The noble Lords, Lord Goodlad, Lord Farmer and Lord Bradley, among others, have outlined some statistics—and I have some more. We know that at least one in four people will experience a mental health problem at
	some point in their life. Mental health problems are the single largest cause of disability in the UK, contributing up to 22.8% of the total burden, compared to 15.9% for cancers and 16.2% for cardiovascular diseases. It is estimated that the wider economic costs of mental illness in England are, according to anyone’s figures—and we have heard several this afternoon—enormous.
	The noble Lords, Lord Patel and Lord Goodlad, raised the issue of parity of esteem. This has been a game-changing issue. The Government’s commitment to prioritising mental health is encapsulated in the principle of parity of esteem—equal priority for mental and physical health—which was set out in our 2011 mental health strategy, No Health Without Mental Health. This commitment to parity was made explicit in the Health and Social Care Act 2012. Many noble Lords here will remember that vote well and many will be grateful for it.
	The 2014-15 mandate to the NHS sets an explicit target for NHS England to make measurable progress to ensure that,
	“everyone who needs it has timely access to evidence-based services”.
	My noble friend Lady Janke referred to the challenges posed by those who only attend emergency and crisis services. In October 2014, NHS England set out its vision on the future of the NHS in its Five Year Forward View. This recognises that,
	“the NHS must drive towards an equal response to mental and physical health, and towards the two being treated together”.
	As part of that commitment, for the first time ever, waiting time standards will be introduced in mental health services in 2015-16. My noble friend Lady Tyler referred to these. They will include: 75% of people referred to the Improving Access to Psychological Therapies programme will be treated within six weeks of referral, and 95% will be treated within 18 weeks of referral; and at least 50% of patients experiencing a first episode of psychosis will be treated with a NICE-approved care package within two weeks of referral.
	On the subject of child and adolescent mental health services, my noble friend Lord Addington spoke movingly about the fact that, if people are different, mental health problems can follow them. He spoke about dyslexia, dyspraxia and autism. It is estimated that 50% of mental illness in adult life begins before the age of 15 and that 75% of mental illness in adults starts before the age of 18. Early intervention is known to reduce not only the incidence, duration and severity of lifelong mental health problems, but also the cost of mental health problems to the economy. We will invest £30 million a year over the next five years to improve services for young people with mental health problems. We are also investing £54 million over the period 2011 to 2015-16 in the Children and Young People’s IAPT programme, to transform child and adolescent mental health services. In August we set up the Children and Young People’s Mental Health and Wellbeing Taskforce, to focus on innovative solutions to improve outcomes for children and young people’s mental health. It will report to Ministers in spring this year.
	My noble friend Lord Storey brought his experience as a head teacher to the debate. I can tell him that I have recently spoken to the Care Minister, Norman
	Lamb, on the issues that he mentioned, about how things will work and the work that will be going on with the Department of Health to try to nail some of those problems.
	Mental health crisis care is crucial. People in mental health crisis need speedy access to safe and compassionate care in the right environment. My noble friend Lady Janke gave us an example of a multidisciplinary, multiagency approach in Bristol—the Golden Key approach. We know that an effective response can often prevent an in-patient admission, which is disruptive to an individual’s life and their well-being, as well as costly to the taxpayer. It can also help to avoid totally unacceptable admissions a long way away from people’s homes. The first national crisis care concordat was published in February 2014 to improve service responses to people in mental health crisis and, in particular, to keep people in mental distress who have committed no crime out of police cells. The concordat—the noble Baroness, Lady Chisholm of Owlpen, spoke about the Cambridge one—is a national commitment for agencies to work together to support people in crisis to find the support that they need.
	The 2014-15 mandate to NHS England specifies that NHS England must make rapid progress, working with clinical commissioning groups and other commissioners, to help to deliver on the shared goal to have,
	“crisis services that, for an individual, are at all times as accessible, responsive and high quality as other health emergency services”.
	That picks up on the question asked by the noble Lord, Lord Patel. I can report that, as of 22 December 2014, every local community now has its own local crisis care declaration in place. Local action plans, most of which are expected in the first quarter of 2015, will make sure that improved crisis care is embedded in services for years to come. I have too many responses to contain in this speech, so I will use this opportunity in answer to the noble Lord’s question on how these will be followed up and monitored to say that that will go out in a letter that I shall send to all Peers.
	On offender health, my noble friend Lord Suri brought up the important issue of mental health in prisons. I congratulate him on his maiden speech and look forward greatly to his work in your Lordships’ House. I can assure the noble Lord, Lord Ramsbotham, that the NHS provides treatment and care according to clinical need, so offenders, irrespective of gender, should receive the same range and quality of treatment and services as anyone else. Offenders within the criminal justice system—whether in the community or outside—with mental health needs should have their treatment delivered in the most appropriate setting, whether in prison or in the community. We should listen to his wise words on the issue of young offenders’ mental health. We have committed £25 million to introduce a new standard service specification of liaison and diversion services in England to identify and assess the health issues and vulnerabilities of all offenders when they first enter the criminal justice system. Prison healthcare has improved significantly since the NHS first became responsible for commissioning it in 2006 and it continues to improve. But we should not be complacent. The noble Lord, Lord Ramsbotham, also mentioned health
	and well-being boards. These were set up locally to meet local needs, so the frequency of their meetings will be determined locally, not nationally.
	On mental health information, the lack of mental health data is an issue that goes to the heart of equal priority for services. We do not have the same level of information on mental health services as we do for physical health. Information that has proved so critical in driving improvement and service change in the rest of the NHS is either absent or incomplete for mental health. We are driving forward plans to address gaps in mental health information on prevalence, waiting times and access, outcomes, spend, uses of out-of-area placements and restraint. To further the parity agenda, data from across the health and care system has, for the first time, been brought together on the NHS Choices website. Key in this is the inclusion of a specific mental health section. This level of data will help to facilitate evidence-based decision-making, drive up quality and standards and ensure genuine accountability for the services provided. It will, in time, create the most transparent mental healthcare system in the world.
	The noble Lord, Lord Goodlad, raised the issue of schizophrenia and questioned why little progress had been made on schizophrenia research. More than £400 million is being invested over the spending review period to make choices of psychological therapies available for those who need it. We are investing in improving provision, including for those with severe mental health conditions.
	Data are also vital to research, helping us to provide the evidence that we need to transform services. Investment in mental health research by the National Institute for Health Research—the NIHR—has nearly doubled in the past four years, from £40 million in 2009-10 to £72 million in 2013-14, and we will continue to support the work of the NIHR and the network of specialist clinical research facilities in the NHS.
	From September 2014, more than 800,000 people with the most complex physical and mental healthcare needs are benefiting from the Proactive Care Programme. This is being delivered through an enhanced service to the GP contract. Many of these people will have complex physical and mental health needs and this initiative will ensure that they get personalised, joined-up care and support, tailored to their needs.
	NHS England is working with commissioners to make mental health a bigger priority, with better integration of physical and mental healthcare in primary care and, indeed, in all settings. Improving the diagnosis of mental illness is one of four national goals for 2014-15. Providers will be rewarded for better assessing and treating the mental and physical needs of their service users.
	The issue of training for GPs was raised. The Royal College of General Practitioners has a programme around training. However, there are two issues: one is the training of new GPs before they go out and practise; the other is the ongoing training of GPs in all the new developments. The noble Lord, Lord Bradley, raised the issue of the mental health workforce. Health Education England has increased training places for mental health nurses by 3.2% for 2015-16.
	As for mental health unemployment, getting people back to work is a priority for the Government. Jointly with the Department for Work and Pensions, we commissioned external policy advice from RAND Europe on how we can achieve better outcomes for people with common mental health problems. Based on the recommendations put forward this year, we are taking forward a number of feasibility pilots to explore the most promising and evidence-based approaches.
	My noble friend Lord Addington addressed the issue of ensuring awareness among healthcare professionals of potentially vulnerable groups. As the mandate to NHS England makes clear,
	“everyone who needs it should have timely access to evidence-based services”,
	including people with autism and learning disability. In line with the Equality Act, we expect all service providers to make reasonable adjustments so that disabled people are not placed at a disadvantage compared with non-disabled people.
	My noble friend Lady Tyler raised the issue of Time To Change, the country’s largest anti-stigma and anti-discrimination mental health campaign—indeed, several other noble Lords mentioned it—which the department currently funds by up to £4 million a year. Between December 2012 and December 2013, we have seen a 20% decrease in the number of life areas in which people experience discrimination. On discrimination for black and minority ethnic patients, this Government are committed to tackling inequalities in access to mental health services. The commitment to reduce inequalities is in our action plan, Closing the Gap. The 2014-15 mandate to NHS England makes it clear that everyone should have access to the mental health services that they need.
	On the issue of mental health and perinatal health for mothers, the mandate to NHS England includes an objective for NHS England to work with partner organisations to reduce the incidence and the impact of post-natal depression through earlier diagnosis and better intervention and support.
	On the budget, mental health funding is not ring-fenced. However, we expect commissioners to demonstrate parity of esteem when agreeing financial statements. Aggregate CCG expenditure is not yet available for 2013-14, but NHS England advises that total mental health spending in 2013-14 was £11.3 billion with an estimated £11.6 billion planned for the following year—an increase of £302 million.
	There are many other issues that I will write to noble Lords about. I am proud of the Government’s record on mental health, of the role of my honourable friends Paul Burstow and Norman Lamb in the other place and of the commitment and leadership of the DPM. But as the noble Baroness, Lady Tyler, has highlighted, there is still more to be done. I would not want to suggest any complacency on the part of the Government on this vital issue. I feel confident that, whatever May brings us, Members of your Lordships’ House will keep the feet of the new Government well and truly to the fire on issues of mental health. I particularly thank the noble Lord, Lord Farmer, and the noble Baroness, Lady Tyler, for giving us some ideas for the new Government to start with.

Baroness Tyler of Enfield: My Lords, this has been an excellent debate drawing on the wealth of expertise, knowledge and first-hand experience of all the speakers. I thank all noble Lords who spoke and especially commend my noble friend Lord Suri for his excellent maiden speech. I also thank the many local health organisations that provided me with briefing; I particularly thank Mind for its help.
	I do not think that anyone who listened to the debate this afternoon could be in any doubt about the strength of feeling on this issue, the importance of mental health to the country’s well-being or indeed the scale of the challenges ahead. Those challenges are for central government, but also for the NHS, local councils, the voluntary sector, communities and, indeed, families.
	I leave noble Lords with one thought: many speakers this afternoon, myself included, talked about or implied that the problem was around the issue of institutional bias against mental health within the NHS. I feel that that sort of culture has started to change, given that one quarter of the population in this country experience mental health problems at one time or another, a quarter of all managers in senior leadership positions have a mental health background and a quarter of all the thinking and doing time in the NHS is spent on mental health.
	Motion agreed.

Insurance Bill [HL]

Insurance Bill [HL]

Third Reading

Bill passed and sent to the Commons.

Developing World: Maternal and Neonatal Mortality
	 — 
	Question for Short Debate

Baroness Hayman: To ask Her Majesty’s Government what progress has been made in reducing maternal and neonatal mortality in the developing world; and what plans they have to build on this work post-2015.

Baroness Hayman: My Lords, I am grateful for the opportunity to introduce this debate, and delighted that noble Lords from all Benches of your Lordships’ House are planning to contribute on this important issue. I declare my interests in health and development, particularly my chairmanship of the external advisory group of the Centre for Maternal and Newborn Health at the Liverpool School of Tropical Medicine.
	It was in this role that last year I visited Zimbabwe and saw for myself the power of the Making it Happen programme run by the centre in 11 countries, supported by DfID. I saw UK volunteers, an obstetrician and a midwife, together with Zimbabwean master trainers who had been through the course before, supported by
	the country’s Ministry of Health, running the course for Zimbabwean health workers, giving them the skills to save the lives of mothers and babies and to pass on those skills to their colleagues to ensure sustainability and improved services countrywide.
	I will step back from the specific to address the scale of the problem. The statistics are chilling. Some 300,000 women die every year; 800 women die every day in pregnancy and childbirth; 50 will die in the course of this short debate. There are an estimated 2.6 million stillbirths and 3 million neonatal deaths every year; half of those neonatal deaths occur in the first 24 hours of life. A child dies somewhere in the world every five seconds, overwhelmingly of preventable causes.
	These maternal and neonatal deaths are not evenly distributed. The maternal mortality ratio shows the highest discrepancy: the greatest gap between high and low income settings of all international health indicators. In the UK, the maternal mortality ratio is eight per 100,000. In Sierra Leone, it is 110 per 100,000. That is the last figure that we have; I hate to think what the figure will be for the last 12 months when the ravages of Ebola have put into abeyance the most basic health services that were available in the past. The average for neonatal mortality in developed countries is 3.7 per 1,000 live births; in southern Africa and south-east Asia it is 10 times that; 99% of all maternal deaths and 98% of all neonatal deaths occur in low or middle-income countries.
	Within developing countries there are wide variations, with the poorest, the youngest, the least educated, and the rural women most at risk. The deaths are not the end of the story. For every woman who dies in childbirth, it is estimated that 20 to 30 live but suffer lifelong morbidity such as fistula. The health and survival of babies is dependent on the health and survival of mothers, not only in the quality of antenatal, intra-partum and post-partum care, but evidenced by the fact—I have lost the reference for this statistic, but I am sure someone will tell me—that a motherless child is 10 times more likely to die in the first two years of its life than a child who has a mother to care for them.
	It was the recognition of this tsunami of suffering and the obstacle to development that the figures represent—because we all know how crucial women are to development—that led to the introduction of millennium development goals 4 and 5, of reducing child deaths by two-thirds and maternal deaths by 75% by 2015. When the Minister comes to answer the question posed in the title of this debate, I am certain that she will outline the considerable progress that has been made since 1990.
	I pay tribute to the work that has been done in developing countries by DfID and other international agencies in just about halving those deaths. The figures have been helped of course by the progress in other MDGs, for example in relation to HIV/AIDS and malaria, and perhaps point us again, looking forward, to the importance of joined-up healthcare and healthcare for all.
	However, it is disappointing that the progress that has been made has, again, not been evenly distributed, and that some of the countries that have the worst
	figures, and which need the greatest improvements, are ones that have seen the least change in their statistics. I ask the Minister to address the issue of how, post-2015, we attend to the unfinished business in the millennium development goals and ensure that we do not take our eye off the ball in these hugely important areas where we need to make sustained efforts in order to continue with the progress made so far.
	I have not said a lot so far about the causes of maternal and newborn mortality, and how this terrible toll of death and suffering can be reduced. That is partly because when I asked a local expert for help in preparing for this debate and what she thought I ought to stress and what ought to be said, she shrugged her shoulders and said, “There is nothing new to say. We know what the issues are and we know how they can be addressed. What are needed are the resources and the political will to do it”.
	You can go through the list of causes of maternal and newborn death: poor nutrition, existing medical conditions—which are often the diseases of the poor, such as malaria—unsafe abortions, infections, eclampsia, haemorrhage and obstruction in labour. The last three of these can be addressed by specific programmes of maternity care, but the first are much wider issues relating to water and sanitation, education for girls, an end to child marriage, immunisation programmes, and access to family planning and antenatal intra-partum and post-partum care from trained and skilled birth attendants. That is where programmes such as Making a Difference can have profound effects: in the first phase of those programmes, maternal death rates in areas where they had been implemented reduced by as much as 50%. The decision we have to make globally is about the priority that we give to the quality of women’s lives and the numbers of women’s deaths.
	In the early 17th century, Joseph Hall, who was then Bishop of Exeter, wrote:
	“Death borders upon our birth, and our cradle stands in the grave”.
	That is no longer true in this country. It need no longer be true in the developing world. But to stop it being the reality for millions in that world, we have to put the resources and the priority into work to reduce maternal and neonatal deaths.

Lord Bourne of Aberystwyth: As the debate gets under way, I respectfully remind noble Lords that this is a time-limited debate.

Baroness Hodgson of Abinger: My Lords, nearly every minute of every day a woman dies from complications in pregnancy and childbirth. Yesterday 800 women across the world died; 800 will die today and every day until the end of the year and into next. On average, 9,000 babies will die at birth or in the first week of life each day of this year too. In this day and age these are truly shocking figures.
	I congratulate the noble Baroness, Lady Hayman, on having secured this debate which encompasses two of the most important millennium development goals—to reduce child mortality and to improve maternal health. Of course, these two goals go hand in hand and I am heartened that the title of this debate recognises it.
	There has been improvement. Since 1990, maternal mortality has declined by nearly half. Although progress has been made in all developing regions, as we have already heard, there are vast geographical disparities and it is now estimated that 99% of maternal deaths occur in developing countries. In 2013, the maternal mortality ratio in developing countries was 230 per 100,000 live births, compared to 16 per 100,000 in the developed world. For example, one woman in 30,000 dies as a result of pregnancy and childbirth in Sweden, whereas in Afghanistan it is about one in six. So many of these deaths are preventable. These women will not have had the pain relief and epidurals that we have come to expect here. Many will have had to endure many hours of excruciating and unbearable pain before they die.
	Neonatal mortality rates have also declined significantly over the past 20 years, but to have between 3 million and 4 million babies a year currently dying is truly appalling Cocooned in the Palace of Westminster, we might find these overwhelming impersonal statistics numbing, but we should remember that each and every one of these deaths is a devastating tragedy for those involved. It is a tragedy for the children who lose a mother—and children who have lost their mothers are 10 times more likely to die prematurely—and a tragedy for the mother who loses a baby. In the West these losses are mercifully rare but, having lost a baby at birth myself, I know personally that it is a very hard thing ever to come to terms with.
	For every woman who dies, at least 20 more suffer complications which may leave them with lifelong crippling disability and pain. Lack of obstetric care may result in fistula, resulting in them being shunned by their families and the community. Traumatic births can cause postnatal depression—something rarely mentioned in the context of developing countries. Today in the UK, 10% to 20% of women develop a mental illness during pregnancy or within the first year after having a baby. With the right help, women can recover but, without that help, they may never be able to function properly again. For a baby, even slight oxygen deprivation at birth may cause life-changing damage—either physical or mental.
	Many of these deaths are avoidable but, to ensure the fundamental well-being and survival of both mothers and babies, every woman needs access to a trained doctor or midwife. In countries such as Afghanistan, only 14% of births are attended by a health worker. Every year, across the world, 46 million babies are delivered without any skilled assistance.
	I have seen the challenges from my visits to various countries. For example, I remember visiting the district hospital in Koinadugu in Northern Province, Sierra Leone a few years ago. There was only one doctor in the hospital, who was also the district health administrator. He explained that some of the villages in the district were 100 miles away from the hospital and there were no roads. Although there was a system of outlying clinics, none had doctors and most had no trained nurses either. The radio system to them from the hospital was broken. There are similar tales in many other developing countries. So it is not just about ensuring that there are enough doctors and midwives in these countries; it is also about ensuring that the medical care that is so vitally needed can be reached.
	Harmful traditional practices such as FGM and early marriage, all too prevalent in some developing countries, also contribute to maternal and child mortality. Lack of adequate nutrition can also be a cause. Lack of gender equality impacts, too. For example, there are clear connections between women’s lack of access to education and reproductive rights and health. In some countries, girls commonly have to leave school due to pregnancy or for early marriage—that is, if they have attended school at all. I recently visited Mali, which has one of the highest child marriage rates in the world. Half of the girls there will be married before they are 18. In addition to greater vulnerability to domestic violence and the contracting of diseases, these child brides are more likely to bear children before they are physically ready, thus exposing them to extreme risk. Newborn baby deaths are also 50% higher when born to those under 20.
	Women need to be empowered in a wider cultural sense by having control over their sexual and reproductive activity. It is estimated that 215 million women in the developing world want to delay or avoid pregnancy, with as many as 50% of pregnancies being unplanned and 25% unwanted. Having to have baby after baby wears a woman out, with each pregnancy multiplying her chance of dying from complications. It is estimated that a third of these deaths could be avoided if women had access to contraception services, which would help avert unintended and closely spaced pregnancies and reduce instances of unsafe abortions. This is because one-quarter of all pregnancies end in abortion and 19 million of those abortions are unsafe, resulting in 68,000 deaths per year and many women suffering complications and infections. So the provision of proper contraception is crucial in improving reproductive health and tackling maternal mortality.
	I particularly welcome the debate today, as in spite of the improvement of the last 20 years the situation is still unacceptable. We need to be resolute in tackling the causes in developing countries because we still have a long way to go until every woman and child across the world receives the care that we, in the western world, take for granted.

Baroness Kinnock of Holyhead: My Lords, I, too, thank the noble Baroness, Lady Hayman, for introducing this debate and for doing so in such a compelling and expert way.
	In large parts of the world, poverty means that great numbers of women die from a lack of family planning, an inability to negotiate the number and spacing of children, the lack of money to pay for skilled birth attendance or emergency obstetric care, and violence. In spite of some welcome progress, it is clear that MDG 5, on reducing maternal mortality and achieving universal access to reproductive health, is far from being fulfilled. However, as affirmed by the UN Commission on the Status of Women, the elimination of preventable maternal mortality is possible in the next decade but it will, clearly, require a major scaling-up of our efforts. Does the Minister agree that sexual and reproductive healthcare for women and girls should be a specific priority, separated from maternal health, so that its allocation and impact can be properly measured?
	Is the Minister aware that around only 1% of ODA is currently allocated to family planning?
	DfID has also committed to,
	“enable 10 million more women to access family planning (of which 1 million will be girls aged 15-19)”.
	How confident is the Minister that this objective can be met, since only 4,966,000 have been reached to date? Does the Minister agree that, as DfID spending on humanitarian assistance is increasing, it is vital that a comprehensive package is offered in emergency settings, such as conflicts and disasters, and that this should include access to sexual and reproductive health?
	The UN high-level panel established to prepare the post-2015 agenda for action estimates that 800 women die every day from complications related to pregnancy and childbirth and, according to the WHO, 99% of those maternal deaths occur in developing countries. In addition, medical experts testify that, globally, every year there are about 80 million unplanned pregnancies and 20 million unsafe abortions with the result that, as Marie Stopes International points out:
	“Worldwide, one woman dies every 11 minutes from an unsafe abortion”.
	Unsafe abortion is a major cause of maternal mortality and remains a major public health and human rights concern. Being able to make an informed choice and take control of your own reproductive health is surely a basic right. Does the Minister agree with the view that Governments and donors need to prioritise what women want, rather than what they feel most comfortable with doing and providing? Such a change is urgent. I remember talking to Beth outside her home in rural Tanzania. Such were the perils of childbirth that before she went into labour she would say goodbye to her children. Giving life should surely not mean taking such a risk.
	A post-2015 assessment says that aiming to reduce newborn mortality by 70% will prevent 2 million child deaths every year. Such evidence highlights the urgent need to provide expectant mothers with nutrients, protection against disease, nursing care, clean water and hygiene facilities. All these initiatives can save precious lives and are taken for granted in the developed world. No girl should die giving birth and no child should die because its mother is too young. Each year around 1 million babies born to adolescent girls die before their first birthday.
	These issues go beyond family planning. Campaigns and condom distribution are irrelevant to women and girls who simply do not have the power to make the decisions. A country’s current status and future prospects are clearly illuminated by examining, for instance, the lifetime risk of maternal death, the percentage of women using modern contraceptives, women’s literacy rate, their participation in national growth and the enrolment of girls in school.
	The reality is that gender inequality remains a major propellant of poverty and women’s marginalisation, and a basic cause of underdevelopment. Faced with that reality, it is clear that little will change until the underlying root causes of discrimination are plainly and publicly identified as gender inequality and pervasive,
	discriminatory norms. Religious, cultural and social barriers impose overt discrimination that stands in the way of women’s freedom to choose.
	One hundred and ninety-three Governments are currently gearing up for the UN discussion, at September’s annual meeting, on priorities for the next decade and a half. Currently, there are 17 goals and 169 targets. However, we can safely say that there will be a stand-alone goal on gender equality, women’s rights and empowerment. This will include universal access to sexual and reproductive health, and rights to be mainstreamed across all other goals. The task is to prevent an estimated 640,000 newborn deaths and 150,000 maternal deaths each year, which will result in 600,000 children having to grow up without a mother. When motherless children are 10 times more likely to die within two years of their mother’s death, the urgency is graphically obvious.
	To achieve such advances we will indeed need political leadership. When fundamental rights are upheld, women, girls and young people can thrive. They can gain education, get better jobs with better wages and therefore reach their full potential. That objective is essential and, I believe, achievable. It will serve every interest. It must gain active support. The British Government have a duty to take the lead in that mission.

Lord Patel: My Lords, I join the noble Baroness, Lady Hayman, in the tribute that she paid to DfID for the work that it has done and continues to support in areas of reducing maternal and child mortality. I emphasise that in the hope that DfID will not now stop but put extra vigour in joining other partners in delivery until we achieve the goals.
	As has already been said, the statistics—which will be cited by others—are horrendous. A woman giving life should neither die nor go through childbirth only to have the heartbreak of losing her child at birth or in infancy. The noble Baroness, Lady Hodgson, described her experiences, which I well understand. Yet for many mothers and their children this is a reality. Three hundred thousand women die every year during pregnancy. For children, the statistics are worse. There are 131 million births a year; of these, 6.3 million children die before the age of five. That is 17,000 deaths of children every day. One million babies are stillborn. Two million die in the first week of life, and for 1 million babies the day of their birth is the day of their death. While progress in reducing maternal and infant deaths has been significant over the past two decades, many millions continue to die, and 223 million children under five died between 1990 and 2013. Four out of five deaths of children aged under five occur in sub-Saharan Africa.
	While the number of deaths of children under five has declined, the decline in the number deaths around birth and in the first month of life is not so striking. Neonatal deaths now account for 44% of deaths of children under five. There has been no noticeable reduction in neonatal deaths. Some interventions focused on the 24 hours after birth hold great potential for reducing maternal and neonatal deaths. We know the causes of death and how to prevent them, but we have not succeeded in delivering health interventions widely and consistently throughout the world or in developing sustainable health systems.
	Two-thirds of neonatal deaths occur in 10 countries, and 48%—nearly half—occur in four countries: India, China, Nigeria and Pakistan. Two-thirds occur in only two countries, India and Nigeria, and both of them are capable of developing health systems that would stop them, so what must we do to encourage them to strengthen their health systems?
	The causes of neonatal deaths are pre-term births, complications at birth, infections and sepsis and congenital abnormalities. Basic, cost-effective care in the first hour after birth results in significant reductions in maternal and neonatal mortality. For example, breastfeeding in the first hour of life reduces deaths by 40%, yet only 50% of newborns are breastfed in the first hour of life, particularly in vulnerable parts of the world. Skilled attendants at birth and the use of a maternal and neonatal checklist which includes simple tasks, such as cord care, dramatically reduces neonatal mortality, yet 44% of women in some countries do not have skilled attendants, and even when there are attendants at birth, simple interventions are not delivered. For example, only 10% of babies delivered by skilled attendants received seven key neonatal interventions, so we must ask why, even when there are skilled attendants, they do not happen. Hence, we have developed a checklist for maternal and child health at the time of birth to try to make sure that those interventions, including breastfeeding, can be delivered.
	The charity, SafeHands, of which I am a patron, as is the noble Baroness, Lady Kennedy of The Shaws, who is not in her place, tries to use education using visual media in rural villages in Ethiopia and other countries to deliver messages about the importance of basic care and attendants at birth, which can have dramatic effects.
	What of the future? The world needs to fulfil the promise made to the children of this world in 2000. The MDG 4 target will not be met in 2015. At the current rate, it will not be met until 2026. We need a new commitment, not just the targets of 2015, even if we could meet them in 2026. We need a new commitment to children going beyond MDG 4 that by 2035 every country will see a neonatal death rate of 10 per 1,000 births and a stillbirth rate of 10 per 1,000 births. The challenge could be 20 by 2035, to mothers and their babies underpinned by helping to establish sustainable health systems.
	The UK Government have done so much to advance these causes and lead the world. What commitment will they make beyond 2015 towards efforts to reduce maternal and childhood deaths?

The Lord Bishop of Derby: My Lords, I too congratulate the noble Baroness, Lady Hayman, on securing this debate and on introducing it with such expertise and such a challenging sense of the statistics. Millennium development goals 4 and 5 are not being met and, as other speakers have said, the consequences are horrendous. My contribution will be from my own experience working with people at the grass roots, and I will then tease out what the implications of that experience should be.
	I work in the diocese of Derby, in England, and we are twinned with the Church of North India, which extends from Calcutta to Mumbai—the whole of north
	India is twinned with our diocese in an ecumenical link. I work with people in a number of Indian communities where this issue is enormous. In 2012, one-third of global neonatal deaths happened in India. The highest rate of first-day mortality is in India. That is the context in which we are working with our partners, through whose eyes we discern some factors.
	The first, as other noble Lords have said, is poverty. People just do not have the means to call medical help and there is no local infrastructure available anyway even if they could. That kind of poverty is a major factor. The second factor is the lack of education about basic hygiene. I visited slums in Calcutta with the Cathedral Relief Service, which trains very young girls of 10 to 12 to wander in and out of people’s houses, giving good advice about hygiene and childcare. This helps families learn good practice in an unthreatening way and will produce a new generation of young mothers with those skills. This is a practical, grass-roots response.
	My colleagues in India would say that the third factor is that a lack of respect for women and girls is behind these terrible statistics. The attitude so often is that this is their role—illness is not taken seriously—and their job is to run the household. New mothers are expected just to get up and carry on with things. Fourthly, in the urban areas, the issue is not so much a matter of the infrastructure being hundreds of miles away but that whole families live on pavements and give birth there. I was in Calcutta in December and saw families living in the street with no resources, cutting the cord with an ordinary knife because that was all that was at hand.
	That was a snapshot of some of my experiences; what are the responses? I work with ISPCK—the Indian version of the publishing house—and the Cathedral Relief Service in Calcutta. As the noble Baroness, Lady Kinnock, was hinting, they say that the key is to have strong, empowered women. Research by the Cathedral Relief Service in Calcutta shows that 63% of pregnant women in the slums are anaemic. That is an appalling starting place. I visited a slum where they had just invented a green goo to give to people to build up their resources—I had to taste it, and it was a really testing moment in intercultural activity. People have to take this kind of local initiative to build, literally, physically strong women.
	Women have to be empowered, too, and many people in development know that it is by building up women that families survive and have structure and leadership. We spend a lot of time in our diocese raising funds to create around providing sewing machines for women so that the family has a livelihood. This year, we are raising funds to create businesses for recycling in Delhi, where all the waste from industrialising India needs dealing with. It is only by giving women that kind of strength and security that they will be able to deal with some of the issues about family planning and their self-respect and standing in the community.
	Other things that we do with our partners include running education and immunisation programmes, as well as doing home visits. We show films in the slums, and some villages have health days, when volunteers go out and gather people around. So what are the implications that I am learning? The key one is partnership.
	There is a partnership between the people of Derbyshire and people in the slums and rural areas of India around this issue, which provides practical help and tries to empower women and provide infrastructure.
	I am privileged to be a trustee of Christian Aid, which specialises in partnership working with local agencies. We work in Kenya, Malawi and Bangalore, in India, and there are lots of stories that I could tell—like the ones from Derbyshire—of partnership working. Most exciting is our partnership at the moment with DfID. The Minister came to the Christian Aid carol service and launched a match funding scheme for a project in Kenya on this very topic. We should congratulate the Government on their approach to partnering with organisations such as Christian Aid, which have a lot of expertise on the ground and grass-roots connections and can deliver real change. I am proud of the way that our Government are investing in that. Clearly, we can always do more and clearly we need millennium development goals that will challenge the Government more, but I record on behalf of Christian Aid our positive experience of working with DfID and what a good job comes out of it.
	I finish with two questions for the Minister. If developing countries need encouragement to ensure provision for maternal healthcare, what can the Government do to up their game about partnership with those who have grass-roots contacts? That is where we need to operate—with those who are excluded at grass-roots level. We need to connect with those people. How can the Government up their game, working in partnership and investing their funds, while using their influence with other Governments for grass-roots activities?
	Secondly, we all know that a lot of problems in developing countries are caused by the unsatisfactory tax base. So much of what could be raised by taxation to provide money for health and other infrastructure is shifted out of the country by the way that corporations operate financially. Both the Prime Minister and the Chancellor have spoken out against this practice, commendably, and we have had debates in this House about it. I would be interested to know what the Minister thinks about the part that getting a better tax structure in developing countries plays if we are to equip people in their own places to take up this work and meet the challenge.

Baroness Tonge: My Lords, I, too, thank the noble Baroness, Lady Hayman, for bringing this matter to the attention of the House. As chair of the All-Party Parliamentary Group on Population, Development and Reproductive Health and president of the European forum of the same name, it is a subject that has occupied most of my waking hours in the last few years. Indeed, sexual and reproductive health occupied the whole of my professional life before I was elected to the other place.
	I am constantly dismayed when I talk to colleagues about maternal mortality and family sizes. I get back the same old mantra. “Oh”, they say, “we can’t do anything about it—people in developing countries need big families because they have to have people to
	look after them in their old age and they need people to work in the fields. They’ve got to have big families—you mustn’t prevent them from doing that”. We have all been working hard in this Government, and in DfID in particular, to convince those Members that that is no longer the truth.
	We have heard a lot of statistics, and I welcome their repetition; we should have them fixed in our head. But in fact maternal mortality is reducing—there is some good news. It has reduced by some 50% in the past 20 years; now around 250,000 women die per annum. That is still far too many, but it is reducing. With that figure goes the estimate that 2 million neonatal deaths occur per annum—and we know that they are linked.
	We must also remember, as all Members have pointed out, that it is not just maternal deaths. They hide the fact that maternal morbidity and terrible conditions after childbirth, such as fistula—of which I know the noble Lord, Lord Patel, has had such experience and on which he has done so much incredible work—are also very important and account for millions of women being unable to take proper part in family life and look after their families properly because of childbirth. All are due to lack of proper medical and obstetric care and to other factors such as too-early marriage, child marriage, forced marriage, violence in marriage—but most of all, in my view, they are due to a lack of family planning, which enables women to control their own bodies and voluntarily space the number of children that they have.
	We know that more than 2 million women in developing countries would use birth control entirely voluntarily if they had access to it. That is a fact. It has been disregarded in the past, but thanks to the efforts of parliamentarians here, Governments such as our own, and the Bill and Melinda Gates Foundation, a great effort is now being made to get family planning supplies out to those women who need them.
	In 2012, our own Government—and I am very proud to mention and applaud this—held a great family planning summit. Pledges were made from all over the world and progress has been made. Since then, 8.4 million more women are now able to control the number of children that they have: that is in a report from the organisation Family Planning 2020, which was set up to monitor the pledges given at the summit and see that they were being delivered. This is all happening despite tradition, despite their religion, despite all the excuses given in the past—especially the one that we need children to look after us in or old age. I am constantly telling my children that.
	I hope that our colleagues in both Houses will take note and realise that maternal health—and family planning in particular—is the way to sustainable develop -ment. The World Bank, no less, has pointed out that sustainable development and a steady rise in a country’s GNP follow a reduction in family size or fertility rate in that country. We know now that it is not the other way around. Sexual and reproductive health and rights, including family planning, are essential for sustainable development. We are pretty sure, too, that fewer people will mean less environmental degradation; my all-party group is doing an investigation into this subject at the moment.
	There are other advantages for us, too, when this happens. Less international aid will be required in the long term; there will be bigger markets for our goods, if that interests noble Lords; and—dare I say it—there will be less migration from those countries for a better life in the West. Let us say that loud and clear: if they do not listen to our arguments on maternal health and reproductive health and rights, tell them that; tell that to UKIP and tell those people who disregard the importance of international development.
	I am still concerned that this message is not being taken as seriously as it should be by the United Nations body deciding on the action needed after 2015, as was touched upon by the noble Baroness, Lady Kinnock. At that time, the millennium development goals should have been achieved. We know that MDG5 on maternal mortality will not be achieved: there is not a hope.
	The European forum of which I am the president—I want to tell your Lordships about this—has Members of Parliament from 25 countries in Europe and beyond. It includes members from Russia and Turkey; it is not just the European Union. We liaise with, and have encouraged the formation of, similar parliamentary groups to ours and similar forums in Australasia and Africa. All those parliamentarians all over the world are having meetings and making declarations on the very things we have been talking about this afternoon—impressing on their Governments, when they go back home from their meetings, that this is the line that they must take, both in their own country and internationally.
	The international parliamentary conference on the implementation of all these declarations, meetings and forums that have taken place among parliamentarians was held in Stockholm earlier this year. Some of us went from our all-party group. This conference agreed that sexual and reproductive health and rights—remember all those elements—should be high on the list for the post-millennium goals agenda. That was only after lobbying the office of the UN Secretary-General after an unsatisfactory interim report was published that did not mention sexual rights or sexual health. It mentioned just reproductive health.
	We finally got some movement. We lobbied, and the parliamentarians got together and wrote letters and started making a fuss about this, after all our efforts. I am glad to say that last week we heard from the Secretary-General’s office that the final version of what is called the synthesis report—sorry about the terminology; it is not mine—which was released on Christmas Day, of all days, included the words,
	“women’s sexual and reproductive health and reproductive rights”.
	That has moved us forward quite a bit: it is mentioned, that is good, they are looking at it. However, the word “rights” still applies only to “reproduction” and not to “sexual”, which means that there is disagreement and concern about a woman’s right to safe abortion, which was mentioned by several speakers. Even after rape, we are still unsure whether women can get a safe abortion. There is no protection against FGM, for example. So we must keep putting on the pressure.
	I am sorry, I have nearly finished. I fully understand that these are sensitive issues and I hope that the Minister can tell us that our Government—who have worked so hard on these issues in the last five years and held two
	special conferences this year alone to deal with FGM and sexual violence in conflict—will insist, at the final conference in September at the UN on the post-MDG agenda, that these issues will be dealt with in full.
	Sexual and reproductive health and rights are human rights. We talk about the empowerment of women very glibly, but we cannot ensure that until we allow women to have control over their own bodies. We simply cannot. Women all over the world are depending on us to release them from the position to which they are condemned. We must not let them down.

Lord Alton of Liverpool: My Lords, we are all greatly indebted to my noble friend Lady Hayman for instigating this debate and for the way that she introduced it. As she told us, my noble friend is chair of the external advisory group of the Liverpool School of Tropical Medicine’s Centre for Maternal and Newborn Health. Her work for the school has given it very great encouragement. For more than 30 years I have been privileged to be associated with the work of the school and serve as an honorary vice-president. The centre designs and implements innovative healthcare packages, and offers unique expertise in research and in developing evaluation frameworks. It works collaboratively and strategically with Governments and global agencies, saving the lives of women in countless countries, along with the lives of their babies.
	Professor Nynke van den Broek, who is head of the Centre for Maternal and Newborn Health, graphically sets out the scale of the challenges that face developing countries in reducing maternal and neonatal mortality. She says that an estimated 300,000 women die each year from complications in pregnancy and childbirth and—as the noble Baroness, Lady Tonge, said a few moments ago—this represents a decline. The school says it is about 45% overall since 1990. However, this should not lead us to any kind of complacency because it still equates to a woman dying every 90 seconds or 800 women a day. There are also at least 2.6 million stillbirths every year and an additional 2.9 million neonatal deaths. At least 43% of deaths in children under five occur in the first month of life.
	The World Health Organization says that 99% of all maternal deaths occur in developing countries. Inevitably, this loss of life is at its most acute in rural areas and—as the right reverend Prelate the Bishop of Derby said—in poorer communities. UNICEF reminds us that more than 50% of women still deliver without the assistance of skilled health personnel, with 80% of maternal deaths caused by direct obstetric causes. Pivotal to addressing this shocking and avoidable loss of life is the challenge of improving the health and nutrition of mothers and providing access to good-quality support services for mothers-to-be and newborns, before and after birth.
	At a personal level, two decades ago I was struck by what a difference those factors could make. While working in Namibia, my sister gave birth to my niece at 32 weeks’ gestation. My niece weighed less than two pounds and no baby as small as that had previously survived in Namibia. I was told that important to her survival was her mother’s breast milk and the antibodies
	it contains, but obviously she was too small to be able to suckle. There was no electric breast pump available at the hospital. I was able to buy one and ship it out. How different the outcome would have been if she had been living in the bush or a remote village without access to resources. That is surely the challenge we have to address.
	Consider this tale of two countries: 2013 data highlight UK maternal mortality rates as standing at eight deaths in every 100,000, with three neonatal deaths for every 100,000 live births. By contrast, in Zimbabwe—visited by my noble friend—there are 470 maternal deaths in every 100,000 and 39 neonatal deaths for every 100,000. The vast majority of stillbirths, newborn deaths and maternal deaths occur around the time of birth and in developing countries. Ultimately, the health and survival of babies depends on the health and survival of mothers and that requires resources.
	It has, of course, been crucial that millennium development goals 4 and 5 have helped to shape the agenda for action to improve these health indicators. That progress has been made is borne out in the report Financing Global Health 2013 from the Institute for Health Metrics and Evaluation. It noted a welcome increase of nearly 18% in development assistance for maternal, newborn and child health. Although I join others in congratulating DfID on the role it has played in this, nevertheless the spending per live birth remained at just £32 per child.
	Even where death does not occur, failure to provide resources and care at this crucial moment in a woman’s life can have, as we have heard, long-term consequences. For each maternal death, an estimated 20 to 30 women live but suffer lifelong morbidity including a fistula, which my noble friend Lord Patel has done so much work to tackle and was mentioned by my noble friend Lady Hayman. In addition, there is chronic infection, anaemia and infertility. The Liverpool School of Tropical Medicine is currently working with the World Health Organization to develop new tools to provide more detailed data—something that DfID might want to support.
	Improving the availability and quality of data helps to capture and understand the reasons for maternal and neonatal deaths, and to develop the necessary initiatives to prevent deaths. Digging deeper into the currently available statistics, it starts to become clear where we should concentrate our resources and our efforts. Baseline surveys under the Liverpool School-led and DfID-funded Making it Happen programme show that across 11 countries early newborn care packages are simply not consistently available. Out of 749 hospitals and health centres, only 173 were able to provide the required emergency obstetric care package, which is 23.1% or less than one in four. A study of reasons for unavailability of the care package shows that in 17% to 75% of cases there was lack of functioning equipment; in 13% to 17% of cases the reason was lack of a staff cadre—doctors or senior midwives—able to lead the team or provide the more technical aspects of care; and in 2% there was a reported lack of drugs. Not surprisingly, then, sub-Saharan Africa accounts for 62% of all maternal deaths, followed by south Asia with 24%.
	As my noble friend Lord Patel reminded us, two countries stand out: Nigeria and India. India accounts for 17% and Nigeria 14% of the total. The right reverend Prelate told us of his experiences in India. It is one of the world’s greatest nations, yet in its treatment of women, from conception to death, India justifies its title as the land of paradoxes. A 2012 report by the United Nations Department of Economic and Social Affairs found that the ratio of boy to girl deaths is severely skewed. Between 2000 and 2010, 100 girls aged one to five died for every 56 boys. Putting that into plain language, an Indian baby girl is almost twice as likely as an Indian boy to die before the age of five, and the problem seems to be getting worse. In 1961, 976 girls were born for every 1,000 boys, and in 2011 that number was 914. The horror stories that have filled Indian papers, describing bodies of baby girls decomposing in heaps by refuse pits or being discovered in their scores in rubbish bins, should rouse our consciences, and I should like to hear from the Minister when we last raised this issue with the Government of India.
	Another country that stands out and, because of Ebola, is much on our minds is Sierra Leone. It is estimated to have the highest ratio of maternal deaths, with 1,100 per 100,000 live births. This estimate was made in 2013 and the situation then was bad enough, but obviously, with the inevitable decline in the infrastructure in Sierra Leone today, the situation is getting worse. I hope that the Minister will be able to say something about that.
	Are we involved in the formulation of new development goals to ensure continued global advocacy and to ensure that action is under way? A proposed new goal is universal health coverage. Surely a universal gold standard, strengthening health systems worldwide and ensuring that care for mothers and babies is available, accessible and affordable, is one that the United Kingdom should be championing.
	As we look at best and worst practice, do we ask what was done well, what was not done well, how care can be improved in the future and how much involvement there is of users and providers? Are we working to see the better development of perinatal audit and cause classification for maternal deaths, and the introduction of an urgently needed system to identify the cause of, and contributing factors to, stillbirth? I hope that my noble friend’s initiative today will help us to achieve some of those life-saving objectives. I am indebted to her for giving us the opportunity to contribute to this debate.

Lord Collins of Highbury: My Lords, I, too, thank the noble Baroness, Lady Hayman, for initiating this important debate.
	As we have heard, the UN estimates that over the past two decades the under-five mortality rate has almost halved; and the number of deaths of children under five is being reduced faster than at any time in the past two decades, partly due to increased access to vaccination against deadly childhood diseases. As we have heard, the number of women dying in pregnancy and childbirth has also been cut by almost half in the same period.
	However, as we heard from the noble Baroness, Lady Hayman, this progress has not been even because women, adolescents and children from poor and marginalised communities are being left behind. Noble Lords have referred to the fact that nearly 800 women die every day in pregnancy and childbirth, and HIV/AIDS remains the leading cause of death for women aged between 15 and 44.
	With little control over their lives, millions of adolescent girls are forced into early marriage, putting them at risk of complications from pregnancy and HIV at a young age. Faced with an unintended pregnancy, many women and girls resort to unsafe abortion, which accounts for 13% of all maternal deaths; and for every woman who dies, 20 others suffer illness, injury or disability.
	As we have heard, mothers and babies face the greatest risks in sub-Saharan Africa, which accounts for 62% of all maternal deaths, followed by south Asia, with 24%. As the noble Lord, Lord Patel, said, two countries account for one-third of all maternal deaths: India, with 17%, and Nigeria, with 14%. It is worth repeating these statistics, because those are countries that we now consider middle-income countries, which do not need development support. But inequality there is growing rather than diminishing.
	The noble Baroness, Lady Hayman, highlighted the maternal mortality ratio, showing the highest discrepancy of all health indicators—the gap between high and low-income settings. Sierra Leone has been mentioned: it is estimated to have the highest MMR, at 1,100 per 100,000 live births—and as we have heard, this estimate is from 2013, before the Ebola epidemic. There is emerging evidence that as a result of the Ebola epidemic more maternal deaths are occurring, both as a result of the virus and as a result of lack of availability of routine care, with the focus on care for patients with Ebola and the collapse of existing health systems—which were, as we have heard, incredibly weak already. I do not know how many noble Lords heard the BBC’s excellent report yesterday highlighting the additional risks to healthcare workers treating pregnant women with Ebola. It was a shocking story.
	We have heard about millennium development goal 5a, to reduce maternal mortality by 75% between 1990 and 2015: 11 countries are “on track” to meet it, 63 countries are “making progress”, and 13 are “not on track”. Factors associated with making progress include leadership, working in partnership, using evidence, and being innovative and able to adapt using both long and short-term strategies.
	Maternal and newborn health are closely linked. As we have heard, motherless children are up to 10 times more likely to die within two years of their mother’s death. More than 6 million children under five died last year, primarily from complications of prematurity and birth, pneumonia, malaria and diarrhoea, with under-nutrition a major factor. The survival rate of the most vulnerable children—newborns—is improving too slowly: 44% of deaths under the age of five occur in the first month.
	As we have heard, nearly all maternal, child and newborn deaths are preventable. Strong health systems, with sufficient skilled health workers and reliable supplies
	of affordable essential commodities, medicines and vaccines, providing equitable access to universal health care, are critical. Proven strategies to improve maternal and newborn health include increasing access to quality care in pregnancy and childbirth, including emergency obstetric and newborn care, reproductive healthcare and information, family planning services and, most importantly, safe abortion.
	Poor nutrition is an underlying factor in almost half of all child deaths under the age of five. The UK Government are a leader in the fight against hunger and under-nutrition, but can the Minister assure the House that all bilateral maternal and child health programmes include a strong nutrition component? The next Labour Government will put universal health coverage at the heart of the global development agenda. Universal health coverage affirms the right of every person to have the opportunity for the highest standard of health, without suffering financial hardship or poverty as a result. It does not just help improve health outcomes, but would help reduce inequality and stop 100 million people a year falling into poverty. Health and economic development are interdependent. Healthy populations are more productive.
	It is clear from this and other recent debates in this Chamber that universal healthcare will make countries more resilient to humanitarian disasters and outbreaks of disease. The ability of Nigeria, which has a relatively strong healthcare system, to contain and beat the Ebola virus this year sharply contrasts with the experience of Sierra Leone and Liberia, whose health systems were weak. Universal healthcare is a clear and quantifiable goal. Will the Minister commit the Government to it in considering the language of the health goal in the SDGs when negotiations start in New York next week? What is her department doing to ensure that the next development framework is ambitious and trans- formational to end all preventable, maternal, child and newborn deaths?
	As we have heard from my noble friend Lady Kinnock, addressing the underlying causes of ill health and mortality is also critical. As we heard from the right reverend Prelate the Bishop of Derby, this means investing in women’s empowerment, girls’ education, preventing gender-based violence and ensuring access to clean water and sanitation. Will the Minister highlight what the UK Government are planning and doing to address these underlying causes?

Baroness Northover: My Lords, like other noble Lords, I pay tribute to the noble Baroness, Lady Hayman, for securing today’s debate, and for her long-standing commitment to maternal and neonatal health. I commend the other contributions we have heard today, which, as ever in your Lordships’ House, have ranged very widely. I also thank noble Lords for their tributes to DfID for our work. We have heard the devastating figures, and as my noble friend Lady Hodgson pointed out, a human face was given to those figures.
	The noble Baroness, Lady Hayman, my noble friend Lady Hodgson, the noble Baroness, Lady Kinnock, the right reverend Prelate, the noble Baroness, Lady
	Tonge and now the noble Lord, Lord Collins, have all pointed out that this relates fundamentally to the rights of women and their unequal status, unequal access to nutrition and education and being forced into early marriage—we have heard the range of challenges. Gender inequality is key.
	This is a very timely debate, coming right at the start of 2015, the final year of the millennium development goals and the year in which new goals will be agreed at the UN in September. Globally, as the noble Baronesses, Lady Hayman and Lady Tonge, said, we have made significant progress in reducing maternal mortality. The maternal mortality ratio dropped by 45% between 1990 and 2013. Each region of the world has seen significant improvement, though none, as noble Lords pointed out, has yet reached the goal of a 75% reduction in mortality.
	These improvements have been driven largely by more women having access to skilled birth attendants—nearly 70% of births now take place with a skilled attendant. I note what the noble Baroness, Lady Tonge, and the noble Lord, Lord Alton, said about the high level of maternal morbidity. I pay tribute to the All-Party Parliamentary Group on Population, Development and Reproductive Health for its outstanding report, Better off Dead?, as well as to the work on fistula by the noble Lord, Lord Patel. It is not just a matter of physical morbidity. As my noble friend Lady Hodgson pointed out, the mental health of mothers is key. I hope that my noble friend will be pleased to note that mental health is included in the targets for the SDGs proposed by the open working group.
	The noble Baroness, Lady Hayman, noted the number of neonatal deaths and that it had not moved in the direction that maternal mortality had. The MDGs did not include targets for newborns; consequently, they received less attention and less progress has been made. The noble Lord, Lord Patel, in particular emphasised how much more we still need to do. Nearly 3 million newborns still die every year, accounting for around 44% of all deaths of children under five, and 1 million of these die on their first day of life, as noble Lords noted. Eighty-five per cent of newborn deaths result from three preventable causes, as the noble Lord, Lord Patel, and other noble Lords pointed out.
	The noble Lord, Lord Patel, emphasised the high incidence of neonatal deaths in a few countries, identifying particularly large numbers in the populous countries of India and Nigeria—the noble Lords, Lord Collins and Lord Alton, made reference to that as well. As the noble Lord, Lord Patel, noted, it is shocking to see the proportion of babies not breastfed in the first 24 hours. I was shocked when I visited India early last year to discover that this was indeed widespread. I can assure the noble Lords, Lord Patel and Lord Alton, that prioritising women and girls and seeking to address neonatal health is uppermost in our discussions in India. My right honourable friend Lynne Featherstone has been to India this week as a champion to combat violence against women and girls, so it is very high in the Government’s priorities.
	As noble Lords made clear, faster progress in these crucial areas will be achieved only when girls and women are able to access the care and services that
	they need when they need them. They include better nutrition, access to education and access to clean water and sanitation. The United Kingdom has a strong track record of working to improve maternal and newborn health—and I thank noble Lords again for their tributes. In 2010, we made commitments to save 50,000 maternal lives and 250,000 newborn lives by the end of 2015, and we intend to meet them. We have already exceeded our target for maternal lives saved through a combination of increased investments in family planning, skilled birth attendants and making health systems stronger—all issues that noble Lords addressed. A number of noble Lords emphasised family planning, and we share their view that this is crucial, which is why we emphasised it at the London summit in 2012. A recent report shows that we are broadly on track to meet our commitments. Nevertheless, we are not complacent; we know how extremely important that issue is.
	I agree with the noble Baroness, Lady Kinnock, that we need to make sure that we have adequate funding for sexual and reproductive health and that that includes funding from the country Governments themselves. The summit was encouraging, and I hope that the noble Baroness was able to see the commitments that came forward. We need to make sure that those are delivered. We agree that it is vital that girls and women should be able to access comprehensive packages of sexual and reproductive health.
	Ensuring that the post-2015 development agenda continues to advance the social, economic and political empowerment and human rights of girls and women remains a top priority for the United Kingdom, and we will continue to work tirelessly to ensure that the final framework advances the needs of girls and women. The noble Baroness, Lady Kinnock, mentioned prioritising what women want in terms of safe abortion. Where girls and women have taken the decision to terminate a pregnancy, our aim is to ensure that they do not put their own lives at risk. Improving access to safe abortion saves maternal lives and reduces maternal ill health; I stress that very strongly.
	Beyond international targets, we know what is needed on the ground. We need to see high-quality reproductive midwifery and emergency obstetric services being delivered through well functioning health systems. There is much more that we need to do. Most of these deaths are preventable. We must ensure that clear targets for improved sexual and reproductive health and rights are included to prevent maternal and newborn deaths. They must be secured in a post-2015 framework. We are working extremely hard on this and anything that noble Lords can do working with southern voices in these next crucial months is vital.
	My noble friend Lady Tonge mentioned the omission of “sexual rights” from the UN Secretary-General’s recent synthesis report. This report is one of many inputs into the process. We still wish to see the full sexual and reproductive health and rights package reflected in the final framework. We need to ensure that women can access contraceptives if they wish to prevent pregnancy and, if they become pregnant, have access to skilled health workers who have the right drugs and equipment at the right time in the right place to be able to respond
	to complications during pregnancy and childbirth. I was very moved at the Christian Aid carol service to hear some of the stories from Kenya.
	We need health financing systems that mean women do not have to make choices between accessing care and feeding their families. I agree with the right reverend Prelate in terms of finance that a sustainable solution can come only when countries finance their own healthcare adequately. He is absolutely right that tax reform is a key part of that.
	We need supporting information systems that tell us whether our efforts are working and how and where to improve them, ideally taking advantage of new technologies, as the noble Lords, Lord Alton, Lord Collins and others mentioned. All this is why universal health coverage must be an important part of the post-2015 agenda. Strong health systems are vital. It is because Sierra Leone and Liberia have fragile health systems as fragile countries that the Ebola epidemic was able to take hold. That is why we are involved in such countries and why such health strengthening has received 20% of DfID’s budget.
	We need to continue to work on the social determinants of health, such as poverty, better nutrition, education, and so forth, as I have said. Crucially, as noble Lords have made clear, we need the empowerment of girls and women, to enable them to have voice, choice and control within their households, their wider communities and across their nations. Noble Lords have made a powerful case for that. That means working at every level. I agree with the right reverend Prelate that that clearly involves working at community level and we have our aid-matching system as one of the key mechanisms for that. There are others in our portfolio of support for civil society.
	All this is doubly important when we are talking, as noble Lords have, of the hardest-to-reach groups: the youngest, the poorest, the most geographically isolated and those affected by conflict—those left behind by the progress towards the current MDGs. That is why the new set needs to ensure that they leave no one behind. More rapidly declining rates of maternal and newborn deaths will tell us when we are getting this right.

House adjourned at 6.19 pm.